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therapy, and beta-blockers only in patients without Management of Infections
evidence of significant right ventricular failure.
The most common pathogens in ventricular assist de-
Driveline management is an important part of the vice-related infections are Staphylococcus and Pseu-
long-term care. Use a thoracic driveline exit site and domonas and the most common site of infections
driveline dressings changed every third day are key is the percutaneous driveline exit site. One should
to prevent infections. If trauma to driveline exists site have a low threshold for blood culture collection to
occurs (e.g. dropping the controller, pulling the drive- evaluate for an occult bloodstream infection and
line during physical activities),patients remotely send patients should be aggressively treated with empiric
a picture of their exit site, and if erythema or early- antibiotics after blood cultures are obtained. Empiric
infection are identified, patients are promptly started therapy with cephalexin 500 mg oral every 6 hrs for
on oral antibiotics. 10 days, or doxycycline 100 mg oral every12 hrs for
10 days in patients with a history of/colonized with
All patients are optimized on neurohormonal antago- methicillin resistant Staphylococcus Aureus can be
nists for treatment of heartfailure, to the highest tol- used. The antibiotics are modified accordingly based
erated doses. Transthoracic echocardiography should on culture data. If the initial treatment has not led to
be used periodically(at 30 days, 3 months, then year- resolution of the superficial driveline infection, a 48-
ly) to optimize the ventricular assist device speed. In 72 hrs course of intravenous antibiotics can be used,
setting of recurrent heart failure, cardiac catheteriza- followed by longer oral antibiotic course (14-28 days).
tion in conjunction with echocardiography should be For recurrent superficial driveline infections, patients
used to assess and optimize the device function.
should receive lifetime suppressive coverage. Deep
Atrial and ventricular arrhythmias should be con- driveline infections are treated with intravenous van-
trolled, using specific anti-arrhythmicdrugs (e.g. comycin 15-20 mg/kg mg every 8-12 hrs and pipera-
dofetilide, amiodarone, mexiletine) or cardioversion. cillin/tazobactam4.5 g every 6 hrs for a minimum of 14
The cardiac implantable electric devices should be days. Consideration for surgical exploration,debride-
interrogated every 3 months, at the time of the clinic ment and vacuum assisted closure system should be
visit, in order to correlate potential ventricular assist given early for deep driveline infections.
device malfunction with concomitant arrhythmias.
Management of Atrial and Ventricular
Management of Gastrointestinal Bleeding Arrhythmias
After hospital discharge, the most common cause In patients who develop symptomatic or sustained
of bleeding is the gastrointestinaltract. The reasons ventricular arrhythmias the hemodynamics should
for this common complication are likely related to be optimized with medical therapy and pump op-
the use of antithrombotictherapy, acquired von Wil- timization. Additional medical therapy consists of
lebrand factor deficiency, acquired impairedplatelet beta-blockers (irrespective of the right ventricu-
aggregation, and intestinal angiodysplasia related to lar function)and anti arrhythmic agents (including
continuous flow technology. During the first bleeding amiodarone, mexiletine, and sotalol).For patients
episode the gastrointestinaltract should be explored with refractory ventricular tachycardia, catheter ab-
in detail (upper endoscopy, colonoscopy, capsule lation is an option. Atrial arrhythmias are common
endoscopy and doubleballoon enteroscopy) and the in patients on ventricular assist device support and
identified lesions should be treated. If no lesions are persistent atrial fibrillation has been associated with
identified or if the bleeding is recurrent, further inves- worse right ventricular function and impaired func-
tigations are not performed and patients should be tional capacity. Rhythm control strategies should be
transfused to a hematocrit above 30%. Intravenous used in these patients, and the INR goal should be
or oral iron supplements can be used, but erythro- increasedto 2.5-3 in order to prevent microemboliza-
poietin-stimulating agents should be used, as they tion.Rarely, if needed, catheter ablation can be used.
have been associated with thrombotic complications
in patients with ventricular assist devices. In patients Management of de Novo Aortic Insufficiency
with recurrent bleeding or significant need for trans- Aortic valve insufficiency can develop denovo or un-
fusion, octreotide (monthly injectionsof long acting derlying aortic valve pathology may be exacerbated
octreotide) and/or oral thalidomide have been used after ventricular device implantation. In order to pre-
with good results.
ventit, the valve should be replaced at the time of
implant if there is more than mild regurgitation.The
de novo occurrence of aortic insufficiency is more

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