67 CHAPTER 10: LVAD Implantation Technique

CHAPTER 10
LVAD IMPLANTATION
TECHNIQUE
George Dimeling and Phil Oyer
INTRODUCTION
As with any cardiac surgical procedure, the technical precision
with which a device is inserted can have a profound impact on
the short- and long-term outcomes associated with the inter-
vention. Subtle nuances in technique can affect postoperative
bleeding risks, pump function, and standard surgical complica-
tions like infection and stroke. With the rapid evolution in left
ventricular assist device (LVAD) technology, there is no one-
size-fits-all approach to device insertion. Different engineer-
ing characteristics of newer devices mandate an individualized
approach to implantation. However, there are a number of basic
principles that apply to the field of LVAD surgery regardless of
the device that is being implanted. This chapter will address the
fundamental principles of LVAD implantation.
BASIC IMPLANTATION TECHNIQUE
While there are many variations on the basic theme, there is a
basic system that the surgeon typically follows when implant-
ing a device. Prior to making an incision, the surgeon must
carefully review the transesophageal echocardiogram (TEE) in
order to determine presence of any mitral, tricuspid, or aortic
valvular dysfunction; presence of mural thrombi; or presence
of patent foramen ovale (PFO), which could potentially impair
device function and may need to be addressed surgically before
device insertion. Although minimally invasive or alternative
approaches have been described and employed, typically, the
operation begins with a full median sternotomy. This provides
excellent exposure for initiating cardiopulmonary bypass (CPB),
elevating the heart for inflow cannula insertion and clamping
the aorta for outflow graft anastomosis. A pericardial cradle is
created by placing sutures into the pericardium and looping
them around the retractor in manner that applies tension to the
pericardium, thereby elevating the heart. This maneuver allows
for better visualization and access to the structures of interest
during device insertion.
Prior to administering heparin, a pump pocket is created in
order to create a space for the device to sit in after anastomosis
to the left ventricular (LV) apex. This step of the operation rep-
resents the point at which there is the most variability between
the different device types. First-generation pulsatile LVADs
often require extensive pocket dissection or intraperitoneal
access in order to create enough space for these large devices
(Fig. 101). Second-generation axial-flow pumps are smaller
and require much less dissection in order to permit intracorporeal
implantation. These devices characteristically avoid the pitfalls
of intraperitoneal insertion. With a newer third generation of
LVAD technology (and some second-generation technology)
accomplishing even smaller pump size, pump pocket dissection
has been avoided altogether in some cases by placing the device
inside the pericardium. For an implantable first-generation
device, the pump pocket location depends on the presence of
lung disease or previous abdominal surgery. The options for
pump placement include extraperitoneal (with a pocket formed
below the rectus abdominus and internal oblique muscles and
above the posterior rectus sheath) and intraperitoneal. There are
advantages and disadvantages to each strategy.
1
Extraperitoneal
insertion poses a greater infection risk due to bleeding compli-
cations of pocket dissection. On the other hand, intraperitoneal
insertion exposes the device to the abdominal viscera. In patients
likely to be transplanted, the intra-abdominal placement is often
avoided due to complications explanting the device. Others have
described an approach that utilizes an intraperitoneal pocket
using Gore Dualmesh Plus Biomaterial to shield the LVAD
from the abdominal contents.
2
In a virgin chest (and in newer-generation devices) an extra-
peritoneal pocket is the preferred approach. The inferior aspect
of the midline incision is extended deep through the linea alba
and can be continued above the posterior rectus sheath and
peritoneum (Fig. 102). Once the desired tissue plane has been
accessed, the pocket is extended laterally to the left with blunt
dissection and hemostasis is achieved with electrocautery and
clip placement. For implantation of larger devices, the dia-
phragm is incised either laterally at the level of the LV apex or
medially. Experience has shown that either diaphragmatic inci-
sion will not impair respiratory mechanics. Many devices come
with a mock pump that can be positioned inside the pocket in
order to verify adequate dissection.
After the pump pocket has been prepared, heparin is admin-
istered and CPB is instituted once cannulation has been per-
formed. The VAD is simultaneously prepared on a back table
according to the manufacturers instructions and transferred to
the operative field. Inflow cannula insertion is usually performed
first by selecting a site in the LV apex that is lateral to the left
anterior descending (LAD) artery. Inflow cannulation stitches
can be placed either before or after apical coring. Apical coring
is accomplished either via a cruciate incision with circumferen-
tial tissue removal or with a coring device (provided by many
device companies). Great care must be taken when implanting
a continuous-flow device to position the inflow cannula in such
a way that it is directed away from the septum in the direction
of the mitral valve. Once apical coring has been performed, the
left ventricle is then inspected for thrombus and debrided of
calcium. Trabeculae that might obstruct the flow into the can-
nula are divided. There is often a tendency to not resect enough
trabeculae. As long as the papillary muscles are preserved, gen-
erous resection is preferred. Ten to twelve pledgetted horizontal
mattress sutures are then placed in a ringlike fashion around the
ventriculotomy in an everting fashion (epicardium to endocar-
dium, as shown in Fig. 103). It is essential to get good bites of
10-Joyce_Ch10_p067-071.indd 67 6/17/11 9:46:27 AM
68 SECTION I: Clinical Considerations
tissue, and this may be more easily accomplished by using Tevdek
sutures with a longer needle. In friable ventricular tissue, small
pledgets may actually pull through the muscle during the process
of securing the device. Some centers have utilized a felt ring in
place of pledgets to avoid this complication. These techniques will
redistribute the tension away from the (often friable infarcted)
tissue and provide the added benefit of reducing air entry.
After securing the inflow cannula to the LV apex, the device
is de-aired, with a clamp placed across the vented outflow graft.
With many pumps, the outflow graft is connected after the distal
anastomosis is completed to allow better, continuous venting of
the pump. The pump is placed within the abdominal pocket, and
the length of the outflow graft is measured and trimmed. Ideally,
the graft should lie under the right sternal border and out of
harms way in the event of a redo (particularly in cases where
transplant is anticipated). Driveline positioning is performed,
with two simple concepts employed to prevent late infection:
maintaining adequate distance between the cutaneous incision
and the device and developing a long tunnel that gradually rises
through the preperitoneal plane to the skin. In first-generation
implants, the pocket is often extended laterally to the right of
the linea alba approximately 10 cm at the level of the umbilicus
(Fig. 104). The tunneling device is typically placed through a
skin incision to the right of the umbilicus and tunneled to the
device pocket. Most devices utilize a system whereby the driv-
eline is attached to the tunneling device and pulled through the
tract and the skin where it is secured.
Placement of the outflow cannula can often be performed
by placing a partial occlusion clamp across the ascending aorta.
A longitudinal aortotomy is made with an 11 blade knife and
extended with a Potts scissors. To perform an end-to-side
anastomosis 4-0 or 5-0 Prolene suture is used (Fig. 105). After
completion of the anastomosis, de-airing can be performed by
temporarily releasing the partial occlusion clamp, filling the
graft with blood, and allowing air to escape via an 18-gauge
needle placed in the most superior portion os the graft. Any aor-
tic regurgitation greater than mild on TEE findings is repaired
prior to the insertion of the cannula by arresting the heart
and oversewing the aortic valve. If a PFO is identified with the
intraoperative TEE, it should be closed even if there is no shunt
preoperatively. The shifts in atrial pressures with a single VAD
in place can lead to unwanted desaturation postoperatively. The
need for repair or replacement of the mitral and/or tricuspid
valves in the setting of regurgitant disease remains controver-
sial. In a nonbridge-to-recovery setting, mitral regurgitation
is likely less problematic although in the face of significant
pulmonary hypertension preoperatively, providing a competent
valve may provide earlier and more complete reversal. If only an
LVAD is being placed in the face of poor right ventricular (RV)
Air-vent line skin line
Controller
External
battery
pack
HeartMate
VE LVAD
Heart
Aorta
FIGURE 101. First-generation pulsatile LVADs are characterized by their
large size, relative to newer devices. The implantable pumps require either
extensive pocket dissection or intraperitoneal insertion in order to accom-
modate the large device. (Reproduced with permission from Rose EA, Gelijns
AC, Moskowitz AJ, et al. Randomized Evaluation of Mechanical Assistance for
the Treatment of Congestive Heart Failure (REMATCH) study group. N Engl J
Med. 2001 Nov 15;345(20):1435-1443. Copyright Massachusetts Medical
Society. All rights reserved.)
Aorta
Diaphragm
FIGURE 102. Dissection of the pump pocket. (Reproduced with permis-
sion from Pennington DG, Lohmann DP, (eds). Novacor LVAS implantation
technique. Operative Techniques in Thoracic and Cardiovascular Surgery: A
Comparative Atlas, Vol. 4, No. 4.; 1999, Nov:318-329. Copyright Elsevier.)
10-Joyce_Ch10_p067-071.indd 68 6/17/11 9:46:27 AM
69 CHAPTER 10: LVAD Implantation Technique
function, dealing with tricuspid valve pathology may be benefi-
cial in handling the right side in the postoperative setting.
After de-airing is complete, the patient is weaned from CPB
and the device is activated according to the manufacturers
instructions. Cannulae are removed and hemostasis is achieved.
There are several techniques of draining the surgical site, but
the important concept is one of ensuring minimal areas where
a hematoma can reside with its increased risk of pump pocket
infection. The authors approach is to place one or two chest
tubes in the mediastinum, and a Blake drain is attached to a
Jackson Pratt bulb suction device to evacuate the pump pocket.
The pericardial contents can be covered with a number of com-
mercially available devices to facilitate ease of reentry when the
device is implanted as a bridge-to-transplantation. The sternum
and incisions are closed in the usual fashion, and the driveline
is secured with sutures.
SPECIAL CONSIDERATIONS
REDO STERNOTOMY
Quite frequently, patients have undergone previous cardiac
surgery and the LVAD implantation occurs as either a first or
multiple-time redo procedure. Therefore, careful dissection
using an oscillating saw to divide the sternum is required to pre-
vent hemorrhagic complications of reentry. External defibril-
lation pads are placed to permit treatment of arrhythmogenic
complications. In cases of severe adherence of the dilated right
ventricle (RV) to the sternum, the patient may require periph-
eral cannulation and/or cooling prior to dividing the sternum.
In addition, virtually every LVAD insertion must be performed
with the expectation that the patient will require another ster-
notomy, either for transplant or device changeout (although the
latter represents a much less frequent event with newer device
technology). A number of strategies have been employed to
minimize the danger of reentering the previous sternotomy inci-
sion. Perhaps the most commonly reported approach involves
inserting the device via a left thoracotomy.
3
In this technique,
the patient is positioned in the right lateral decubitus position
(with the left side up) in a similar fashion to positioning for a
A
B
FIGURE 103. Inflow cannula insertion is performed by placing 10 to 12
pledgetted sutures around the ventriculotomy site. (Reproduced with per-
mission from Slater JP, Williams M, Oz MC, et al. Implantation techniques
for the TCI HeartMate left ventricular assist systems. Operative Techniques
in Thoracic and Cardiovascular Surgery: A Comparative Atlas, Vol 4, No. 4;
1999. Copyright Elsevier.)
FIGURE 104. Positioning of the driveline. (Reproduced with permission
Noon GP, Loebe M, Irwin S, et al. Implantation of the MicroMed DeBakey
VAD. Operative Techniques in Thoracic and Cardiovascular Surgery: A
Comparative Atlas, Vol 7, No. 3; 2002:111-170. Copyright Elsevier.)
10-Joyce_Ch10_p067-071.indd 69 6/17/11 9:46:31 AM
70 SECTION I: Clinical Considerations
thoracoabdominal aneurysm repair (both groins exposed by
rotating the hips at 45 degrees). Lung isolation is achieved with a
double lumen endotracheal tube, and cannulation is performed
through the groin. A generous posterolateral thoracotomy inci-
sion is made to permit access to the descending aorta and LV
apex through the pericardium. Implantation proceeds in the
same sequence as through a sternotomy once CPB is initiated,
with positioning of the inflow cannula followed by placement
of a side-biter clamp on the descending aorta to permit anas-
tomosis of the outflow graft. There is some suggestion that a
descending aortic anastomosis reduces recirculatory flow that
may create stagnation at the aortic root, based on computer
flow modeling.
4
OFF-PUMP INSERTION
Several different strategies have been utilized to facilitate LVAD
insertion without the use of CPB. The off-pump approach to
LVAD surgery carries many advantages in redo surgery, where
a prolonged pump run may be associated with worsening end-
organ function, atherosclerosis may limit access to the groin for
cannulation, and excessive manipulation of the heart during
dissection may be poorly tolerated. Frazier and colleagues have
described a nonthoracic, extraperitoneal, off-pump insertion
technique that permits LVAD implantation without the use of
CPB and extensive mediastinal dissection.
5
Using this technique,
exposure to the LV apex was gained through a left subcostal
incision (similar to what one would use for placement of epicar-
dial pacemaker leads) that also permits access to the supraceliac
aorta for outflow graft anastomosis. Alternatively, transdia-
phragmatic insertion of the LV inflow cannula can be achieved
via a left upper quadrant subcostal incision without entering
the peritoneal cavity, mediastinum, or left chest.
6
Off-pump
LVAD insertion has also been described via a redo sternotomy
to expose the ascending aorta for outflow graft anastomosis
and left anterior thoracotomy to minimize manipulation of the
heart during inflow cannula insertion.
7
CHALLENGES OF ABERRANT ANATOMY
In addition to the challenges posed by a redo sternotomy, many
anatomic challenges may be present at the time of LVAD insertion.
Many patients with end-stage heart failure undergo surgical ventric-
ular restoration (SVR) as a strategy for improving cardiac function.
However, some of these patients will suffer from progression of their
cardiomyopathy such that LVAD therapy is required. Williams and
Conte have described the challenges of VAD insertion under these
conditions, whereby the suture line of the reconstructed anterior
wall is identified to guide the surgeon to the apex.
8
In these cases, the
new functional apex is typically more inferolateral to the natural
apex, and the surgeon must be cognizant of this in order to prop-
erly direct the inflow cannula toward the mitral valve.
8
Difficulty in
achieving proper inflow cannula placement can also be seen in cases
of cardiomyopathy secondary to conotruncal abnormalities. These
patients typically have a morphologic RV supplying their systemic
circulation, and inflow cannula positioning can be compromised by
the presence of a bulky moderator band. Joyce et al have promoted
the use of epicardial ultrasound imaging to properly position the
device in a way that promotes flow through the mitral valve.
9
CONCLUSION
There are currently a number of strategies for safely inserting
an LVAD utilizing a variety of different approaches. In the
current era, the default approach for most long-term intracor-
poreal devices involves accessing the mediastinum through a
sternotomy, followed by implantation assisted by CPB. Future
application of newer technology will undoubtedly permit an
increasing use of off-pump and minimally invasive approaches.
REFERENCES
1. Wasler A, Springer WE, Radovancevic B, Myers TJ, Stutts LA, Frazier OH.
A comparison between intraperitoneal and extraperitoneal left ventricular
assist system placement. ASAIO J. 1996;42(5):M573-M576.
2. Icenogle T, Sandler D, Puhlman M, Himley S, Sato DJ, Schaefer S.
Intraperitoneal pocket for left ventricular assist device placement. J Heart
Lung Transplant. 2003;22(7):818-821.
3. Pierson RN, III, Howser R, Donaldson T, et al. Left ventricular assist device
implantation via left thoracotomy: alternative to repeat sternotomy. Ann
Thorac Surg. 2002;73(3):997-999.
FIGURE 105. Exposure for sewing of the outflow graft when the LVAD is
placed via left thoracotomy. (Reproduced with permission fom Pierson et al.
3

Copyright Elsevier.)
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71 CHAPTER 10: LVAD Implantation Technique
4. Kar B, Delgado RM, III, Frazier OH, et al. The effect of LVAD aortic out-
flow-graft placement on hemodynamics and flow: implantation technique
and computer flow modeling. Tex Heart Inst J. 2005;32(3):294-298.
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extraperitoneal, off-pump insertion of the Jarvik 2000 Heart in patients with
previous median sternotomy. J Heart Lung Transplant. 2006;25(5):499-503.
6. Cohn WE, Frazier OH. Off-pump insertion of an extracorporeal LVAD
through a left upper-quadrant incision. Tex Heart Inst J. 2006;33(1):48-50.
7. Collart F, Feier H, Metras D, Mesana TG. A safe, alternative technique for
off-pump left ventricular assist device implantation in high-risk reoperative
cases. Interact Cardiovasc Thorac Surg. 2004;3(2):286-288.
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ventricular restoration. Interact Cardiovasc Thorac Surg. 2006;5(2):90-91.
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with heart failure secondary to transposition of the great arteries. J Heart
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