Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited. 1 ASAIO Journal 2017 Adult Circulatory Support Driveline infections (DLIs) remain a major source of morbid- ity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteris- tics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylo- coccus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1–78.0%) at 1 year and 41.9% (95% CI 21.1–61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m 2 was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI. ASAIO Journal 2017; XX:00–00. Key Words: ventricular assist device, driveline site, infection Implantable left ventricular assist devices (LVADs) are increas- ingly being used as a bridge to heart transplantation and destination therapy for patients with end-stage heart failure. Percutaneous drivelines remain an Achilles heel of this therapy, with driveline infections (DLIs) remaining a major complica- tion, leading to hospitalizations, increasing costs, and potential systemic complications. 1 Identification of strategies to reduce DLI could potentially improve patient autonomy, survival, and quality of life. 2 Patient-related factors that have been found to increase the risk of DLI include obesity, 3 diabetes, 4 degree of illness at the time of VAD implant, 2 and immunosuppression. 5 Various pre- ventative strategies have been attempted to reduce the burden of infections in patients on LVAD support. These strategies include perioperative antibiotics, 6,7 patient education in regard to driveline site care, 8 and prevention of driveline trauma. 2 Sur- gical techniques such as intrafascial tunneling of the driveline 9 and externalization of the silicone rather than the velour part of the driveline 10 have also been reported to reduce DLI. It is unknown whether driveline exit site may be related to the occurrence of DLI. The standard approach to VAD implan- tation involves the driveline exiting the skin through the abdominal wall, generally toward the right lower quadrant. 9 We have adopted a modified driveline implantation technique consisting of tunnelling the driveline to exit through the chest wall. The objective of this study was to examine whether the location of the driveline exit site is associated with the occur- rence of DLI. Materials and Methods From January 2009 to January 2016, 85 patients had 95 HeartWare HVAD or Heartmate II (HMII) Left Ventricular Assist Devices (LVADs) or Biventricular Assist Devices (BiVAD) implanted at the University of Alberta Hospital. Three patients had their second VAD implanted within less than 30 days of their first VAD, and they were only assessed from the time of insertion of their second VAD going forward; there were therefore 92 separate VADs in 85 patients that were included in the analysis. Demographic and clinical information were extracted from inpatient and electronic charts for each subject. All patients were followed from the time of preimplant assess- ment through their surgery and entire postoperative course with no patients lost to follow-up. This study was approved by the University of Alberta Health Research Ethics Board. VAD Implant Technique Patients received prophylactic perioperative antibiotics as per institutional protocol. Device choice was made on an indi- vidual patient basis. Starting in 2014, a selective strategy of passing the driveline through the chest wall was used in VAD recipients. In brief, the patient’s chest wall was evaluated for optimal exit site (approximately 3–5 cm above the costal mar- gin, mid-axillary line) and marked before draping. The driveline was brought through the fascia in the midline, then tunneled over the costal margin and brought through the skin at the marked site (Figure 1). Care was taken to minimize trauma and Driveline Site Is Not a Predictor of Infection After Ventricular Assist Device Implantation BILLIE-JEAN MARTIN,* JESSICA G.Y. LUC,† MICHIKO MARUYAMA,‡ RODERICK MACARTHUR,‡ ANGELA R. BATES,§ HOLGER BUCHHOLZ,† DARREN H. FREED,† AND JENNIFER CONWAY¶ From the *Division of Cardiothoracic Surgery, Stanford Univer- sity, Stanford, California; †Division of Cardiac Surgery, University of Alberta, Edmonton, Canada; ‡Faculty of Medicine and Dentistry, Uni- versity of Alberta, Edmonton, Canada; §Division of Critical Care, Uni- versity of Alberta, Edmonton, Canada; and ¶Department of Pediatrics, University of Alberta, Edmonton, Canada. Submitted for consideration June 2017; accepted for publication in revised form August 2017. Disclosure: The authors have no conflicts of interest to report. Correspondence: Jennifer Conway, MD, Department of Pediatrics, University of Alberta 8440 112 Street NW, Edmonton AB T5G-2B7, Canada. Email: jennifer.conway2@ahs.ca. Copyright © 2017 by the ASAIO DOI: 10.1097/MAT.0000000000000690