Driveline Care; Arrhythmias; Right Heart Failure; Blood Pressure Maintenance - HeartWare Ventricular Assist System Instructions For Use Manual

16.5 Driveline Care*

To minimize the risk of infection, driveline exit site dressings should be changed daily. Routine driveline/exit site care is the responsibility of the patient and the primary caregiver. For
proper HVAD ® Pump driveline and exit site care, please ensure the following:
Use good hand-washing technique before and after dressing changes
1)
2) Always use aseptic technique
Change dressings per institutional protocol/guidelines:
3)
a. Change once or twice daily 24-48 hours after implant (or sooner if saturated)
b. Change BID for drainage, trauma or infection
c. Change daily when all drainage has stopped, the site has good tissue ingrowth and there is no evidence of infection or trauma
d. If present, remove sutures used to retain the driveline 2-3 weeks post-op, when the driveline has good circumferential tissue growth
Once the exit site dressing is removed, the driveline should be visually inspected for kinks, tears or other damage. If blood is seen within the lumen of the driveline, the implanting center
4)
should be notified immediately.
During exit site dressing changes, examine the driveline for evidence of tears, punctures or breakdown of any of the material.
CAUTION:
Perform daily exit site care using an antiseptic cleansing agent, such as a diluted chlorhexidine scrub solution. Following aseptic cleansing, rinse and dry the site to avoid tissue injury.
5)
Aseptic technique should be followed anytime the dressing is removed and the exit site is exposed, inspected, dressed or handled. When performing exit site care, be sure to wear a cap,
mask and sterile gloves.
Prophylactic topical antibiotic ointments such as silver sulfadiazine, povidone iodine, or neomycin bacitracin ointment should not be used. These ointments can
CAUTION:
injure the tissue adjacent to the exit site.
6) Immobilize the percutaneous lead with occlusive dressing and if necessary, a Hollister clip, Montgomery strap, or a custom-made percutaneous lead immobilization binder or belt. Keep
the extra external length of the driveline under a binder or clothing.
Complicated, non-routine driveline dressing changes that involve exit site infections may require assistance/supervision from a health care professional.
7)
8) For wounds/incisions other than the driveline exit site that require dressing changes and/or other care, the ability of the patient and caregiver to provide that care will be evaluated by
the implanting center. Treatment plans will be dependent upon this evaluation.

16.6 Arrhythmias

The HVAD Pump functions most effectively when adequate and stable amounts of preload are available. A stable supraventricular rhythm helps to optimize right heart performance and
®
provide the HVAD Pump with preload. Many heart failure patients will have permanent pacemakers and internal defibrillators in place by the time an LVAD is implanted. These devices
®
are often needed in the early postoperative period.

16.7 Right Heart Failure

Right heart failure is common in patients receiving LVADs. Right heart failure usually develops within the first 24 hours after LVAD implant. Warning signs include increasing right atrial
pressure (RAP) with concurrent decreases in the pulmonary capillary wedge pressure (PCWP) and LVAD flow. Systemic hypotension, tachycardia and a decrease in urine output soon
follow. Volume should be given to increase the RAP to 15-18 mm Hg. This can be accomplished quickly and easily in the operating room while the patient is on cardiopulmonary bypass.
Increasing the RAP to >20 mm Hg is usually ineffective. After optimizing intravascular volume, increasing inotropic drug support in conjunction with pulmonary vasodilators such as nitric
oxide is usually effective. If volume and pharmacological therapy fail then a right ventricular assist device (RVAD) should be considered. Late right heart failure (weeks to months) post
LVAD implant is unusual but would manifest itself with similar but less acute symptoms. The etiology of late right heart failure may be a progression of chronic heart disease such as
coronary artery disease and/or right ventricular infarction. The cause of the right heart dysfunction should be identified and treated appropriately.

16.8 Blood Pressure Maintenance

The restoration of normal perfusion may lead to systemic hypertension in susceptible patients. Since the HVAD
diastolic pulse pressures, it is best to monitor the mean arterial pressure (MAP). MAP should be monitored and maintained at <85 mm Hg. The blood pressure should be manually
auscultated; however, it may be necessary to use a Doppler probe. If unable to manually auscultate a blood pressure or use a Doppler probe or if hypotension precludes either method,
consider placing an arterial line.

16.9 Physical Rehabilitation

Physical Rehabilitation begins as soon as the patient admitted to the intensive care unit is stable. Early extubation, removal of monitoring lines, and patient ambulation are encouraged. Turning
the patient from side to side should start once the patient is clinically stable. Physical therapy and active range of motion may begin on the first postoperative day. The patient may be moved
to a chair and should use a bed bike, exercise bicycle or treadmill as soon as possible. Within a few days of LVAD implant, the patient should be ambulating in the halls and performing mild
exercise under the supervision of a physical therapist. The nursing, physical therapy, and occupational therapy staff will work together to prepare the patient for hospital discharge - whether
to home or a rehabilitation facility. If discharged to home, at the clinician's discretion, the patient may attend a structured outpatient cardiac rehabilitation program.

16.10 Patient Education

Patient training is critical to ensure safe and successful outcomes. The patient must be able to demonstrate proficiency in operating the HeartWare
emergencies. In order to ensure their understanding and ability, patients should be trained using hands-on demonstrations. At the end of the training, the patient should be able to do
the following:
Identify the AC adapter and successfully connect it to the controller and an electrical outlet
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Identify the power ports on the controller and be able to successfully replace batteries as indicated
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Successfully recharge batteries with the battery charger
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Monitor the remaining battery time on each battery using the LED light displays.
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Identify audible and text alarm messages on the controller
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Ventricular Assist System
Pump provides continuous flow, resulting in narrow arterial systolic/
®
® System and in responding to
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Instructions For Use 29