Objective: This case exemplifies the understanding of the physiological changes associate with 1) Left Ventricular Assist Devices, 2) monitoring challenges associated with Left Ventricular Assist Devices and 3) the usefulness of peripheral nerve blocks in this subset of patients. Case report: A 73-year-old man was scheduled for left wrist arthroscopy and debridement to treat a very painful septic joint. He had undergone Heartmate II Left Ventricular Assist Device implantation uneventfully for Destination Therapy 4 months prior. The patient required maintenance of therapeutic anticoagulation. We elected for an ultrasound-guided axillary block, which limits the risks of vascular injury in presence of high INR. The axillary nerve block enabled us to overcome potential anesthetic problems in a patient with a continuous flow LVAD. Conclusion: The physiologic principles of Left Ventricular Assist Device function should be understood before the initiation of anesthesia. Regional Anesthesiologists can offer a very significant contribution to the safe care of patients with heart failure requiring a continuous flow Left Ventricular Assist Device.