PMC:6640909 / 94593-100841 JSONTXT

{"project":"TEST0","denotations":[{"id":"31100109-109-115-7678","span":{"begin":189,"end":191},"obj":"[\"26520247\"]"},{"id":"31100109-113-119-7679","span":{"begin":193,"end":195},"obj":"[\"20123242\"]"},{"id":"31100109-117-123-7680","span":{"begin":197,"end":199},"obj":"[\"23352391\"]"},{"id":"31100109-121-128-7681","span":{"begin":201,"end":204},"obj":"[\"19384093\"]"},{"id":"31100109-126-133-7682","span":{"begin":206,"end":209},"obj":"[\"25612114\"]"},{"id":"31100109-135-142-7683","span":{"begin":215,"end":218},"obj":"[\"21514180\"]"},{"id":"31100109-156-162-7684","span":{"begin":697,"end":699},"obj":"[\"26520247\"]"},{"id":"31100109-160-166-7685","span":{"begin":701,"end":703},"obj":"[\"20123242\"]"},{"id":"31100109-164-170-7686","span":{"begin":705,"end":707},"obj":"[\"23352391\"]"},{"id":"31100109-168-175-7687","span":{"begin":709,"end":712},"obj":"[\"19384093\"]"},{"id":"31100109-173-180-7688","span":{"begin":714,"end":717},"obj":"[\"25612114\"]"},{"id":"31100109-182-189-7689","span":{"begin":723,"end":726},"obj":"[\"21514180\"]"},{"id":"31100109-191-197-7690","span":{"begin":1048,"end":1050},"obj":"[\"26520247\"]"},{"id":"31100109-195-201-7691","span":{"begin":1052,"end":1054},"obj":"[\"20123242\"]"},{"id":"31100109-199-205-7692","span":{"begin":1056,"end":1058},"obj":"[\"23352391\"]"},{"id":"31100109-203-210-7693","span":{"begin":1060,"end":1063},"obj":"[\"19384093\"]"},{"id":"31100109-208-215-7694","span":{"begin":1065,"end":1068},"obj":"[\"25612114\"]"},{"id":"31100109-217-224-7695","span":{"begin":1074,"end":1077},"obj":"[\"21514180\"]"},{"id":"31100109-65-71-7696","span":{"begin":1840,"end":1842},"obj":"[\"23352391\"]"},{"id":"31100109-69-76-7697","span":{"begin":1844,"end":1847},"obj":"[\"25735901\"]"},{"id":"31100109-78-85-7698","span":{"begin":1853,"end":1856},"obj":"[\"21419995\"]"},{"id":"31100109-120-126-7699","span":{"begin":2164,"end":2166},"obj":"[\"23352391\"]"},{"id":"31100109-124-131-7700","span":{"begin":2168,"end":2171},"obj":"[\"25735901\"]"},{"id":"31100109-133-140-7701","span":{"begin":2177,"end":2180},"obj":"[\"21419995\"]"},{"id":"31100109-94-100-7702","span":{"begin":2277,"end":2279},"obj":"[\"23352391\"]"},{"id":"31100109-98-105-7703","span":{"begin":2281,"end":2284},"obj":"[\"25735901\"]"},{"id":"31100109-107-114-7704","span":{"begin":2290,"end":2293},"obj":"[\"21419995\"]"},{"id":"31100109-86-93-7705","span":{"begin":2382,"end":2385},"obj":"[\"21419995\"]"},{"id":"31100109-91-98-7706","span":{"begin":2387,"end":2390},"obj":"[\"25746483\"]"},{"id":"31100109-96-103-7707","span":{"begin":2392,"end":2395},"obj":"[\"23943820\"]"},{"id":"31100109-101-108-7708","span":{"begin":2397,"end":2400},"obj":"[\"24559948\"]"},{"id":"31100109-106-113-7709","span":{"begin":2402,"end":2405},"obj":"[\"25793027\"]"},{"id":"31100109-111-118-7710","span":{"begin":2407,"end":2410},"obj":"[\"26793335\"]"},{"id":"31100109-112-119-7711","span":{"begin":2710,"end":2713},"obj":"[\"21419995\"]"},{"id":"31100109-117-124-7712","span":{"begin":2715,"end":2718},"obj":"[\"25746483\"]"},{"id":"31100109-122-129-7713","span":{"begin":2720,"end":2723},"obj":"[\"23943820\"]"},{"id":"31100109-127-134-7714","span":{"begin":2725,"end":2728},"obj":"[\"24559948\"]"},{"id":"31100109-132-139-7715","span":{"begin":2730,"end":2733},"obj":"[\"25793027\"]"},{"id":"31100109-137-144-7716","span":{"begin":2735,"end":2738},"obj":"[\"26793335\"]"},{"id":"31100109-131-137-7717","span":{"begin":3250,"end":3252},"obj":"[\"23352391\"]"},{"id":"31100109-135-142-7718","span":{"begin":3254,"end":3257},"obj":"[\"25735901\"]"},{"id":"31100109-144-151-7719","span":{"begin":3263,"end":3266},"obj":"[\"21419995\"]"},{"id":"31100109-75-81-7720","span":{"begin":3405,"end":3407},"obj":"[\"23352391\"]"},{"id":"31100109-83-90-7721","span":{"begin":3413,"end":3416},"obj":"[\"24075484\"]"},{"id":"31100109-123-129-7722","span":{"begin":3811,"end":3813},"obj":"[\"23352391\"]"},{"id":"31100109-131-138-7723","span":{"begin":3819,"end":3822},"obj":"[\"24075484\"]"},{"id":"31100109-201-207-7724","span":{"begin":4026,"end":4028},"obj":"[\"23352391\"]"},{"id":"31100109-209-216-7725","span":{"begin":4034,"end":4037},"obj":"[\"24075484\"]"},{"id":"31100109-80-87-7726","span":{"begin":4180,"end":4183},"obj":"[\"20060321\"]"},{"id":"31100109-163-170-7727","span":{"begin":4349,"end":4352},"obj":"[\"28336236\"]"},{"id":"31100109-205-212-7728","span":{"begin":5719,"end":5722},"obj":"[\"30117586\"]"},{"id":"31100109-86-92-7729","span":{"begin":5835,"end":5837},"obj":"[\"23352391\"]"},{"id":"31100109-94-101-7730","span":{"begin":5843,"end":5846},"obj":"[\"26793337\"]"}],"text":"15. OUTPATIENT CARE\n\n15.1 Mechanical circulatory support programme organization\nAn LT-MCS programme requires organization, planning and appropriate personnel to constitute a core MCS team [25, 37, 71, 137, 284, 354–362]. Mid- and long-term success for outpatients on LT-MCS therapy depends on a multidisciplinary approach. Such success is achieved by combining the expertise of MCS coordinators, advanced HF cardiologists, cardiovascular surgeons and other health care providers.\n\n15.2 Discharge after ventricular assist device implantation\nSuccessful discharge planning begins preoperatively, with assessment of the cognitive abilities of the patients, their support system and home environment [25, 37, 71, 137, 284, 354–360]. Training of patients, family and other designated caregivers should be performed in the implanting hospital by the LT-MCS team.\nA clear algorithm for when and how to seek help, including a synoptic card placed in the pocket and in the room of the patient at home with emergency instructions and contacts, is mandatory [25, 37, 71, 137, 284, 354–360]. The MCS team is responsible for informing the general practitioner, the referring physician and the emergency support personnel of the discharge of the patient with MCS. Those involved with the patient should be provided with basic knowledge of the concepts of MCS.\nIt is recommended that discharged patients regularly visit the outpatient clinic. During each visit, the following procedures should be considered: physical examination with special attention for the driveline exit site and blood pressure (BP), laboratory testing (including coagulation and markers of haemolysis), technical examination of the device, chest radiogram and echocardiographic scans.\n\n15.3 Driveline site management\nRoughly half of the patients develop infection of the exit site [71, 259, 363–376], making visual inspection of the wound at every outpatient visit essential. Additionally, attention should be paid to proper driveline positioning and the use of immobilization devices. A photographic record and clinical scoring of the driveline exit site are helpful in tracking its appearance over time [71, 259, 363–376]. The incidence of infection after LT-MCS implantation depends on patient-related risk factors [71, 259, 363–376].\nStrict attention to driveline cleanliness should be ensured from postoperative day 0 [363, 367, 369, 370, 374, 376]. Initially, the dressing should be changed once daily, thus keeping the exit site dry. The use of various anchoring devices to stabilize the driveline helps minimize the risk of trauma.\nThe patients should receive in-house training for driveline care with family members before hospital discharge [363, 367, 369, 370, 374, 376]. After discharge, patients and/or their caregivers should adhere to the proper aseptic technique. A driveline management pack for changing the dressing should be given to the patient. Dressings should be changed by patients and/or their family members and/or their caregivers 1–2 times per week according to the condition of the exit site and the opinion of the VAD coordinator. Since patients with LT-MCS are susceptible to infections, they should avoid situations that could place them at an increased risk [71, 259, 363–376].\n\n15.4 Blood pressure management and heart failure medication\nMany patients still suffer from volume overload after LT-MCS implantation [71, 377–384]. Therefore, most patients require diuretics after LVAD implantation. Diuretic doses must be reviewed regularly to ensure relief of fluid overload and to avoid depletion of intravascular volume, which could result in suction events, pump alarms, arrhythmias and syncope.\nHypertension leads to increased afterload for the LVAD, decreased LVAD flow and less effective left ventricular unloading [71, 377–384]. Furthermore, there is a significant association between Doppler-derived BP and a range of adverse events including intracranial haemorrhage, thromboembolic events and progressive aortic insufficiency [71, 377–385].\nWith CF-LVADs, conventional measurement of BP is difficult. Thus it is common practice to use a Doppler BP reading as the mean systemic BP [382]. Newer oscillometric devices show good correlation of systolic, diastolic and mean pressures in patients with a CF-LVAD in comparison with intra-arterial pressure [378].\nAs a therapy, angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the first-line drugs for post-LT-MCS hypertension. Beta-blockers can be used in combination with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers but caution should be exercised in patients with marginal RV function. These agents may also be useful for rate control in the setting of atrial or ventricular arrhythmias (VAs). Calcium antagonists, especially the dihydropyridines, can be used as a third option. Aldosterone antagonists should be used for their potassium-sparing and antifibrotic effects.\n\n15.5 Driving while on long-term mechanical circulatory support\nEvery country has its own regulations with regards to driving with medical conditions, physician/provider responsibility in reporting these conditions and physician/provider liability for motor vehicle accidents that might occur as a result of these patients driving. According to the literature [386–391], most patients with an LT-MCS, NYHA functional class I–III and stable LT-MCS implantation qualify for private driving only and are disqualified from commercial driving. A recent study shows that a significant number of patients with LT-MCS continue to drive a vehicle after implantation (72%), although the frequency of driving dropped from nearly 80% driving daily to 52% [392].\n\n15.6 Remote monitoring\nRemote monitoring (RM) can aid in outpatient care and surveillance of key parameters [71, 359–362]. RM provides a real-time view and transmission of MCS data via secure wireless Internet-based RM settings, thus potentially avoiding unnecessary hospital visits. The use of RM technology has only recently become available for some LT-MCS systems. Future developments may ease troubleshooting, provide more data from the patient and the pump and eventually increase physician and patient satisfaction."}

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OUTPATIENT CARE\n\n15.1 Mechanical circulatory support programme organization\nAn LT-MCS programme requires organization, planning and appropriate personnel to constitute a core MCS team [25, 37, 71, 137, 284, 354–362]. Mid- and long-term success for outpatients on LT-MCS therapy depends on a multidisciplinary approach. Such success is achieved by combining the expertise of MCS coordinators, advanced HF cardiologists, cardiovascular surgeons and other health care providers.\n\n15.2 Discharge after ventricular assist device implantation\nSuccessful discharge planning begins preoperatively, with assessment of the cognitive abilities of the patients, their support system and home environment [25, 37, 71, 137, 284, 354–360]. Training of patients, family and other designated caregivers should be performed in the implanting hospital by the LT-MCS team.\nA clear algorithm for when and how to seek help, including a synoptic card placed in the pocket and in the room of the patient at home with emergency instructions and contacts, is mandatory [25, 37, 71, 137, 284, 354–360]. The MCS team is responsible for informing the general practitioner, the referring physician and the emergency support personnel of the discharge of the patient with MCS. Those involved with the patient should be provided with basic knowledge of the concepts of MCS.\nIt is recommended that discharged patients regularly visit the outpatient clinic. During each visit, the following procedures should be considered: physical examination with special attention for the driveline exit site and blood pressure (BP), laboratory testing (including coagulation and markers of haemolysis), technical examination of the device, chest radiogram and echocardiographic scans.\n\n15.3 Driveline site management\nRoughly half of the patients develop infection of the exit site [71, 259, 363–376], making visual inspection of the wound at every outpatient visit essential. Additionally, attention should be paid to proper driveline positioning and the use of immobilization devices. A photographic record and clinical scoring of the driveline exit site are helpful in tracking its appearance over time [71, 259, 363–376]. The incidence of infection after LT-MCS implantation depends on patient-related risk factors [71, 259, 363–376].\nStrict attention to driveline cleanliness should be ensured from postoperative day 0 [363, 367, 369, 370, 374, 376]. Initially, the dressing should be changed once daily, thus keeping the exit site dry. The use of various anchoring devices to stabilize the driveline helps minimize the risk of trauma.\nThe patients should receive in-house training for driveline care with family members before hospital discharge [363, 367, 369, 370, 374, 376]. After discharge, patients and/or their caregivers should adhere to the proper aseptic technique. A driveline management pack for changing the dressing should be given to the patient. Dressings should be changed by patients and/or their family members and/or their caregivers 1–2 times per week according to the condition of the exit site and the opinion of the VAD coordinator. Since patients with LT-MCS are susceptible to infections, they should avoid situations that could place them at an increased risk [71, 259, 363–376].\n\n15.4 Blood pressure management and heart failure medication\nMany patients still suffer from volume overload after LT-MCS implantation [71, 377–384]. Therefore, most patients require diuretics after LVAD implantation. Diuretic doses must be reviewed regularly to ensure relief of fluid overload and to avoid depletion of intravascular volume, which could result in suction events, pump alarms, arrhythmias and syncope.\nHypertension leads to increased afterload for the LVAD, decreased LVAD flow and less effective left ventricular unloading [71, 377–384]. Furthermore, there is a significant association between Doppler-derived BP and a range of adverse events including intracranial haemorrhage, thromboembolic events and progressive aortic insufficiency [71, 377–385].\nWith CF-LVADs, conventional measurement of BP is difficult. Thus it is common practice to use a Doppler BP reading as the mean systemic BP [382]. Newer oscillometric devices show good correlation of systolic, diastolic and mean pressures in patients with a CF-LVAD in comparison with intra-arterial pressure [378].\nAs a therapy, angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the first-line drugs for post-LT-MCS hypertension. Beta-blockers can be used in combination with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers but caution should be exercised in patients with marginal RV function. These agents may also be useful for rate control in the setting of atrial or ventricular arrhythmias (VAs). Calcium antagonists, especially the dihydropyridines, can be used as a third option. Aldosterone antagonists should be used for their potassium-sparing and antifibrotic effects.\n\n15.5 Driving while on long-term mechanical circulatory support\nEvery country has its own regulations with regards to driving with medical conditions, physician/provider responsibility in reporting these conditions and physician/provider liability for motor vehicle accidents that might occur as a result of these patients driving. According to the literature [386–391], most patients with an LT-MCS, NYHA functional class I–III and stable LT-MCS implantation qualify for private driving only and are disqualified from commercial driving. A recent study shows that a significant number of patients with LT-MCS continue to drive a vehicle after implantation (72%), although the frequency of driving dropped from nearly 80% driving daily to 52% [392].\n\n15.6 Remote monitoring\nRemote monitoring (RM) can aid in outpatient care and surveillance of key parameters [71, 359–362]. RM provides a real-time view and transmission of MCS data via secure wireless Internet-based RM settings, thus potentially avoiding unnecessary hospital visits. The use of RM technology has only recently become available for some LT-MCS systems. Future developments may ease troubleshooting, provide more data from the patient and the pump and eventually increase physician and patient satisfaction."}

{"project":"0_colil","denotations":[{"id":"31100109-26520247-7678","span":{"begin":189,"end":191},"obj":"26520247"},{"id":"31100109-20123242-7679","span":{"begin":193,"end":195},"obj":"20123242"},{"id":"31100109-23352391-7680","span":{"begin":197,"end":199},"obj":"23352391"},{"id":"31100109-19384093-7681","span":{"begin":201,"end":204},"obj":"19384093"},{"id":"31100109-25612114-7682","span":{"begin":206,"end":209},"obj":"25612114"},{"id":"31100109-21514180-7683","span":{"begin":215,"end":218},"obj":"21514180"},{"id":"31100109-26520247-7684","span":{"begin":697,"end":699},"obj":"26520247"},{"id":"31100109-20123242-7685","span":{"begin":701,"end":703},"obj":"20123242"},{"id":"31100109-23352391-7686","span":{"begin":705,"end":707},"obj":"23352391"},{"id":"31100109-19384093-7687","span":{"begin":709,"end":712},"obj":"19384093"},{"id":"31100109-25612114-7688","span":{"begin":714,"end":717},"obj":"25612114"},{"id":"31100109-21514180-7689","span":{"begin":723,"end":726},"obj":"21514180"},{"id":"31100109-26520247-7690","span":{"begin":1048,"end":1050},"obj":"26520247"},{"id":"31100109-20123242-7691","span":{"begin":1052,"end":1054},"obj":"20123242"},{"id":"31100109-23352391-7692","span":{"begin":1056,"end":1058},"obj":"23352391"},{"id":"31100109-19384093-7693","span":{"begin":1060,"end":1063},"obj":"19384093"},{"id":"31100109-25612114-7694","span":{"begin":1065,"end":1068},"obj":"25612114"},{"id":"31100109-21514180-7695","span":{"begin":1074,"end":1077},"obj":"21514180"},{"id":"31100109-23352391-7696","span":{"begin":1840,"end":1842},"obj":"23352391"},{"id":"31100109-25735901-7697","span":{"begin":1844,"end":1847},"obj":"25735901"},{"id":"31100109-21419995-7698","span":{"begin":1853,"end":1856},"obj":"21419995"},{"id":"31100109-23352391-7699","span":{"begin":2164,"end":2166},"obj":"23352391"},{"id":"31100109-25735901-7700","span":{"begin":2168,"end":2171},"obj":"25735901"},{"id":"31100109-21419995-7701","span":{"begin":2177,"end":2180},"obj":"21419995"},{"id":"31100109-23352391-7702","span":{"begin":2277,"end":2279},"obj":"23352391"},{"id":"31100109-25735901-7703","span":{"begin":2281,"end":2284},"obj":"25735901"},{"id":"31100109-21419995-7704","span":{"begin":2290,"end":2293},"obj":"21419995"},{"id":"31100109-21419995-7705","span":{"begin":2382,"end":2385},"obj":"21419995"},{"id":"31100109-25746483-7706","span":{"begin":2387,"end":2390},"obj":"25746483"},{"id":"31100109-23943820-7707","span":{"begin":2392,"end":2395},"obj":"23943820"},{"id":"31100109-24559948-7708","span":{"begin":2397,"end":2400},"obj":"24559948"},{"id":"31100109-25793027-7709","span":{"begin":2402,"end":2405},"obj":"25793027"},{"id":"31100109-26793335-7710","span":{"begin":2407,"end":2410},"obj":"26793335"},{"id":"31100109-21419995-7711","span":{"begin":2710,"end":2713},"obj":"21419995"},{"id":"31100109-25746483-7712","span":{"begin":2715,"end":2718},"obj":"25746483"},{"id":"31100109-23943820-7713","span":{"begin":2720,"end":2723},"obj":"23943820"},{"id":"31100109-24559948-7714","span":{"begin":2725,"end":2728},"obj":"24559948"},{"id":"31100109-25793027-7715","span":{"begin":2730,"end":2733},"obj":"25793027"},{"id":"31100109-26793335-7716","span":{"begin":2735,"end":2738},"obj":"26793335"},{"id":"31100109-23352391-7717","span":{"begin":3250,"end":3252},"obj":"23352391"},{"id":"31100109-25735901-7718","span":{"begin":3254,"end":3257},"obj":"25735901"},{"id":"31100109-21419995-7719","span":{"begin":3263,"end":3266},"obj":"21419995"},{"id":"31100109-23352391-7720","span":{"begin":3405,"end":3407},"obj":"23352391"},{"id":"31100109-24075484-7721","span":{"begin":3413,"end":3416},"obj":"24075484"},{"id":"31100109-23352391-7722","span":{"begin":3811,"end":3813},"obj":"23352391"},{"id":"31100109-24075484-7723","span":{"begin":3819,"end":3822},"obj":"24075484"},{"id":"31100109-23352391-7724","span":{"begin":4026,"end":4028},"obj":"23352391"},{"id":"31100109-24075484-7725","span":{"begin":4034,"end":4037},"obj":"24075484"},{"id":"31100109-20060321-7726","span":{"begin":4180,"end":4183},"obj":"20060321"},{"id":"31100109-28336236-7727","span":{"begin":4349,"end":4352},"obj":"28336236"},{"id":"31100109-30117586-7728","span":{"begin":5719,"end":5722},"obj":"30117586"},{"id":"31100109-23352391-7729","span":{"begin":5835,"end":5837},"obj":"23352391"},{"id":"31100109-26793337-7730","span":{"begin":5843,"end":5846},"obj":"26793337"}],"text":"15. OUTPATIENT CARE\n\n15.1 Mechanical circulatory support programme organization\nAn LT-MCS programme requires organization, planning and appropriate personnel to constitute a core MCS team [25, 37, 71, 137, 284, 354–362]. Mid- and long-term success for outpatients on LT-MCS therapy depends on a multidisciplinary approach. Such success is achieved by combining the expertise of MCS coordinators, advanced HF cardiologists, cardiovascular surgeons and other health care providers.\n\n15.2 Discharge after ventricular assist device implantation\nSuccessful discharge planning begins preoperatively, with assessment of the cognitive abilities of the patients, their support system and home environment [25, 37, 71, 137, 284, 354–360]. Training of patients, family and other designated caregivers should be performed in the implanting hospital by the LT-MCS team.\nA clear algorithm for when and how to seek help, including a synoptic card placed in the pocket and in the room of the patient at home with emergency instructions and contacts, is mandatory [25, 37, 71, 137, 284, 354–360]. The MCS team is responsible for informing the general practitioner, the referring physician and the emergency support personnel of the discharge of the patient with MCS. Those involved with the patient should be provided with basic knowledge of the concepts of MCS.\nIt is recommended that discharged patients regularly visit the outpatient clinic. During each visit, the following procedures should be considered: physical examination with special attention for the driveline exit site and blood pressure (BP), laboratory testing (including coagulation and markers of haemolysis), technical examination of the device, chest radiogram and echocardiographic scans.\n\n15.3 Driveline site management\nRoughly half of the patients develop infection of the exit site [71, 259, 363–376], making visual inspection of the wound at every outpatient visit essential. Additionally, attention should be paid to proper driveline positioning and the use of immobilization devices. A photographic record and clinical scoring of the driveline exit site are helpful in tracking its appearance over time [71, 259, 363–376]. The incidence of infection after LT-MCS implantation depends on patient-related risk factors [71, 259, 363–376].\nStrict attention to driveline cleanliness should be ensured from postoperative day 0 [363, 367, 369, 370, 374, 376]. Initially, the dressing should be changed once daily, thus keeping the exit site dry. The use of various anchoring devices to stabilize the driveline helps minimize the risk of trauma.\nThe patients should receive in-house training for driveline care with family members before hospital discharge [363, 367, 369, 370, 374, 376]. After discharge, patients and/or their caregivers should adhere to the proper aseptic technique. A driveline management pack for changing the dressing should be given to the patient. Dressings should be changed by patients and/or their family members and/or their caregivers 1–2 times per week according to the condition of the exit site and the opinion of the VAD coordinator. Since patients with LT-MCS are susceptible to infections, they should avoid situations that could place them at an increased risk [71, 259, 363–376].\n\n15.4 Blood pressure management and heart failure medication\nMany patients still suffer from volume overload after LT-MCS implantation [71, 377–384]. Therefore, most patients require diuretics after LVAD implantation. Diuretic doses must be reviewed regularly to ensure relief of fluid overload and to avoid depletion of intravascular volume, which could result in suction events, pump alarms, arrhythmias and syncope.\nHypertension leads to increased afterload for the LVAD, decreased LVAD flow and less effective left ventricular unloading [71, 377–384]. Furthermore, there is a significant association between Doppler-derived BP and a range of adverse events including intracranial haemorrhage, thromboembolic events and progressive aortic insufficiency [71, 377–385].\nWith CF-LVADs, conventional measurement of BP is difficult. Thus it is common practice to use a Doppler BP reading as the mean systemic BP [382]. Newer oscillometric devices show good correlation of systolic, diastolic and mean pressures in patients with a CF-LVAD in comparison with intra-arterial pressure [378].\nAs a therapy, angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the first-line drugs for post-LT-MCS hypertension. Beta-blockers can be used in combination with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers but caution should be exercised in patients with marginal RV function. These agents may also be useful for rate control in the setting of atrial or ventricular arrhythmias (VAs). Calcium antagonists, especially the dihydropyridines, can be used as a third option. Aldosterone antagonists should be used for their potassium-sparing and antifibrotic effects.\n\n15.5 Driving while on long-term mechanical circulatory support\nEvery country has its own regulations with regards to driving with medical conditions, physician/provider responsibility in reporting these conditions and physician/provider liability for motor vehicle accidents that might occur as a result of these patients driving. According to the literature [386–391], most patients with an LT-MCS, NYHA functional class I–III and stable LT-MCS implantation qualify for private driving only and are disqualified from commercial driving. A recent study shows that a significant number of patients with LT-MCS continue to drive a vehicle after implantation (72%), although the frequency of driving dropped from nearly 80% driving daily to 52% [392].\n\n15.6 Remote monitoring\nRemote monitoring (RM) can aid in outpatient care and surveillance of key parameters [71, 359–362]. RM provides a real-time view and transmission of MCS data via secure wireless Internet-based RM settings, thus potentially avoiding unnecessary hospital visits. The use of RM technology has only recently become available for some LT-MCS systems. Future developments may ease troubleshooting, provide more data from the patient and the pump and eventually increase physician and patient satisfaction."}

{"project":"2_test","denotations":[{"id":"31100109-26520247-28905738","span":{"begin":189,"end":191},"obj":"26520247"},{"id":"31100109-20123242-28905739","span":{"begin":193,"end":195},"obj":"20123242"},{"id":"31100109-23352391-28905740","span":{"begin":197,"end":199},"obj":"23352391"},{"id":"31100109-19384093-28905741","span":{"begin":201,"end":204},"obj":"19384093"},{"id":"31100109-25612114-28905742","span":{"begin":206,"end":209},"obj":"25612114"},{"id":"31100109-21514180-28905743","span":{"begin":215,"end":218},"obj":"21514180"},{"id":"31100109-26520247-28905744","span":{"begin":697,"end":699},"obj":"26520247"},{"id":"31100109-20123242-28905745","span":{"begin":701,"end":703},"obj":"20123242"},{"id":"31100109-23352391-28905746","span":{"begin":705,"end":707},"obj":"23352391"},{"id":"31100109-19384093-28905747","span":{"begin":709,"end":712},"obj":"19384093"},{"id":"31100109-25612114-28905748","span":{"begin":714,"end":717},"obj":"25612114"},{"id":"31100109-21514180-28905749","span":{"begin":723,"end":726},"obj":"21514180"},{"id":"31100109-26520247-28905750","span":{"begin":1048,"end":1050},"obj":"26520247"},{"id":"31100109-20123242-28905751","span":{"begin":1052,"end":1054},"obj":"20123242"},{"id":"31100109-23352391-28905752","span":{"begin":1056,"end":1058},"obj":"23352391"},{"id":"31100109-19384093-28905753","span":{"begin":1060,"end":1063},"obj":"19384093"},{"id":"31100109-25612114-28905754","span":{"begin":1065,"end":1068},"obj":"25612114"},{"id":"31100109-21514180-28905755","span":{"begin":1074,"end":1077},"obj":"21514180"},{"id":"31100109-23352391-28905756","span":{"begin":1840,"end":1842},"obj":"23352391"},{"id":"31100109-25735901-28905757","span":{"begin":1844,"end":1847},"obj":"25735901"},{"id":"31100109-21419995-28905758","span":{"begin":1853,"end":1856},"obj":"21419995"},{"id":"31100109-23352391-28905759","span":{"begin":2164,"end":2166},"obj":"23352391"},{"id":"31100109-25735901-28905760","span":{"begin":2168,"end":2171},"obj":"25735901"},{"id":"31100109-21419995-28905761","span":{"begin":2177,"end":2180},"obj":"21419995"},{"id":"31100109-23352391-28905762","span":{"begin":2277,"end":2279},"obj":"23352391"},{"id":"31100109-25735901-28905763","span":{"begin":2281,"end":2284},"obj":"25735901"},{"id":"31100109-21419995-28905764","span":{"begin":2290,"end":2293},"obj":"21419995"},{"id":"31100109-21419995-28905765","span":{"begin":2382,"end":2385},"obj":"21419995"},{"id":"31100109-25746483-28905766","span":{"begin":2387,"end":2390},"obj":"25746483"},{"id":"31100109-23943820-28905767","span":{"begin":2392,"end":2395},"obj":"23943820"},{"id":"31100109-24559948-28905768","span":{"begin":2397,"end":2400},"obj":"24559948"},{"id":"31100109-25793027-28905769","span":{"begin":2402,"end":2405},"obj":"25793027"},{"id":"31100109-26793335-28905770","span":{"begin":2407,"end":2410},"obj":"26793335"},{"id":"31100109-21419995-28905771","span":{"begin":2710,"end":2713},"obj":"21419995"},{"id":"31100109-25746483-28905772","span":{"begin":2715,"end":2718},"obj":"25746483"},{"id":"31100109-23943820-28905773","span":{"begin":2720,"end":2723},"obj":"23943820"},{"id":"31100109-24559948-28905774","span":{"begin":2725,"end":2728},"obj":"24559948"},{"id":"31100109-25793027-28905775","span":{"begin":2730,"end":2733},"obj":"25793027"},{"id":"31100109-26793335-28905776","span":{"begin":2735,"end":2738},"obj":"26793335"},{"id":"31100109-23352391-28905777","span":{"begin":3250,"end":3252},"obj":"23352391"},{"id":"31100109-25735901-28905778","span":{"begin":3254,"end":3257},"obj":"25735901"},{"id":"31100109-21419995-28905779","span":{"begin":3263,"end":3266},"obj":"21419995"},{"id":"31100109-23352391-28905780","span":{"begin":3405,"end":3407},"obj":"23352391"},{"id":"31100109-24075484-28905781","span":{"begin":3413,"end":3416},"obj":"24075484"},{"id":"31100109-23352391-28905782","span":{"begin":3811,"end":3813},"obj":"23352391"},{"id":"31100109-24075484-28905783","span":{"begin":3819,"end":3822},"obj":"24075484"},{"id":"31100109-23352391-28905784","span":{"begin":4026,"end":4028},"obj":"23352391"},{"id":"31100109-24075484-28905785","span":{"begin":4034,"end":4037},"obj":"24075484"},{"id":"31100109-20060321-28905786","span":{"begin":4180,"end":4183},"obj":"20060321"},{"id":"31100109-28336236-28905787","span":{"begin":4349,"end":4352},"obj":"28336236"},{"id":"31100109-30117586-28905788","span":{"begin":5719,"end":5722},"obj":"30117586"},{"id":"31100109-23352391-28905789","span":{"begin":5835,"end":5837},"obj":"23352391"},{"id":"31100109-26793337-28905790","span":{"begin":5843,"end":5846},"obj":"26793337"}],"text":"15. OUTPATIENT CARE\n\n15.1 Mechanical circulatory support programme organization\nAn LT-MCS programme requires organization, planning and appropriate personnel to constitute a core MCS team [25, 37, 71, 137, 284, 354–362]. Mid- and long-term success for outpatients on LT-MCS therapy depends on a multidisciplinary approach. Such success is achieved by combining the expertise of MCS coordinators, advanced HF cardiologists, cardiovascular surgeons and other health care providers.\n\n15.2 Discharge after ventricular assist device implantation\nSuccessful discharge planning begins preoperatively, with assessment of the cognitive abilities of the patients, their support system and home environment [25, 37, 71, 137, 284, 354–360]. Training of patients, family and other designated caregivers should be performed in the implanting hospital by the LT-MCS team.\nA clear algorithm for when and how to seek help, including a synoptic card placed in the pocket and in the room of the patient at home with emergency instructions and contacts, is mandatory [25, 37, 71, 137, 284, 354–360]. The MCS team is responsible for informing the general practitioner, the referring physician and the emergency support personnel of the discharge of the patient with MCS. Those involved with the patient should be provided with basic knowledge of the concepts of MCS.\nIt is recommended that discharged patients regularly visit the outpatient clinic. During each visit, the following procedures should be considered: physical examination with special attention for the driveline exit site and blood pressure (BP), laboratory testing (including coagulation and markers of haemolysis), technical examination of the device, chest radiogram and echocardiographic scans.\n\n15.3 Driveline site management\nRoughly half of the patients develop infection of the exit site [71, 259, 363–376], making visual inspection of the wound at every outpatient visit essential. Additionally, attention should be paid to proper driveline positioning and the use of immobilization devices. A photographic record and clinical scoring of the driveline exit site are helpful in tracking its appearance over time [71, 259, 363–376]. The incidence of infection after LT-MCS implantation depends on patient-related risk factors [71, 259, 363–376].\nStrict attention to driveline cleanliness should be ensured from postoperative day 0 [363, 367, 369, 370, 374, 376]. Initially, the dressing should be changed once daily, thus keeping the exit site dry. The use of various anchoring devices to stabilize the driveline helps minimize the risk of trauma.\nThe patients should receive in-house training for driveline care with family members before hospital discharge [363, 367, 369, 370, 374, 376]. After discharge, patients and/or their caregivers should adhere to the proper aseptic technique. A driveline management pack for changing the dressing should be given to the patient. Dressings should be changed by patients and/or their family members and/or their caregivers 1–2 times per week according to the condition of the exit site and the opinion of the VAD coordinator. Since patients with LT-MCS are susceptible to infections, they should avoid situations that could place them at an increased risk [71, 259, 363–376].\n\n15.4 Blood pressure management and heart failure medication\nMany patients still suffer from volume overload after LT-MCS implantation [71, 377–384]. Therefore, most patients require diuretics after LVAD implantation. Diuretic doses must be reviewed regularly to ensure relief of fluid overload and to avoid depletion of intravascular volume, which could result in suction events, pump alarms, arrhythmias and syncope.\nHypertension leads to increased afterload for the LVAD, decreased LVAD flow and less effective left ventricular unloading [71, 377–384]. Furthermore, there is a significant association between Doppler-derived BP and a range of adverse events including intracranial haemorrhage, thromboembolic events and progressive aortic insufficiency [71, 377–385].\nWith CF-LVADs, conventional measurement of BP is difficult. Thus it is common practice to use a Doppler BP reading as the mean systemic BP [382]. Newer oscillometric devices show good correlation of systolic, diastolic and mean pressures in patients with a CF-LVAD in comparison with intra-arterial pressure [378].\nAs a therapy, angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the first-line drugs for post-LT-MCS hypertension. Beta-blockers can be used in combination with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers but caution should be exercised in patients with marginal RV function. These agents may also be useful for rate control in the setting of atrial or ventricular arrhythmias (VAs). Calcium antagonists, especially the dihydropyridines, can be used as a third option. Aldosterone antagonists should be used for their potassium-sparing and antifibrotic effects.\n\n15.5 Driving while on long-term mechanical circulatory support\nEvery country has its own regulations with regards to driving with medical conditions, physician/provider responsibility in reporting these conditions and physician/provider liability for motor vehicle accidents that might occur as a result of these patients driving. According to the literature [386–391], most patients with an LT-MCS, NYHA functional class I–III and stable LT-MCS implantation qualify for private driving only and are disqualified from commercial driving. A recent study shows that a significant number of patients with LT-MCS continue to drive a vehicle after implantation (72%), although the frequency of driving dropped from nearly 80% driving daily to 52% [392].\n\n15.6 Remote monitoring\nRemote monitoring (RM) can aid in outpatient care and surveillance of key parameters [71, 359–362]. RM provides a real-time view and transmission of MCS data via secure wireless Internet-based RM settings, thus potentially avoiding unnecessary hospital visits. The use of RM technology has only recently become available for some LT-MCS systems. Future developments may ease troubleshooting, provide more data from the patient and the pump and eventually increase physician and patient satisfaction."}