Task Force 4: Inpatient Management of Patients with MCSD - The ...

evision. Driveline infections can be divided into superficial or deep infections that each
have their own specific appearances, diagnostic criteria, and therapies. Each are
divided into proven, probable, and possible with diagnostic criteria that consider the
surgical/histology, microbiology, clinical presentation, and appearance of the wound.
These criteria and definitions are shown in Table 4.
Management of Ventricular Arrhythmias
The incidence of ventricular arrhythmia post MCSD placement has been reported
to range from 22% to 36%. 88-91 In one series, the incidence was as high as 52% in
patients with the HeartMate II axial flow device, with the majority of cases occurring in
the first post-operative month. 92 Early ventricular tachycardia/ventricular fibrillation
(VT/VF) was found to predict future ventricular arrhythmic events in this study. The nonusage
of beta blockers post operatively may be associated with increased ventricular
arrhythmic events, and they should be resumed along with conventional heart failure
oral medications once inotropes and pressors have been weaned. 90
Mechanisms of VT/VF in MCS patients may include reversible factors such as
electrolyte abnormalities, the use QT interval prolonging drugs, and the presence of
“suction events”. 89 Additionally, there may be irreversible factors including the presence
of arrhythmogenic substrate in the cardiomyopathic heart, or formation of new
arrhythmogenic foci resulting from surgical placement of the outflow cannula.
An episode of VT/VF may be well tolerated and resolved with anti-tachycardia
pacing or defibrillation from an ICD. However, incessant ventricular arrhythmias may
occur with repeated failure of the ICD to terminate the event. These events may
produce hemodynamic compromise even in the MCS patient due to resultant RV
dysfunction, as well as significant pain and emotional distress to the patient from
repeated ICD discharges. In these cases, patients require prompt medical attention with
expert involvement of an electrophysiologist. In situations when the arrhythmia cannot
be managed medically, catheter ablation may need to be performed, sometimes
urgently, by an electrophysiologist with the requisite knowledge and experience in
treating these patients. 89
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