Total Artificial Heart Replacement With 2 Centrifugal Blood Pumps Carmelo A. Milano, MD, Jacob Schroder, MD, Mani Daneshmand, MD  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 20, Issue 3, Pages 306-321 (September 2015) DOI: 10.1053/j.optechstcvs.2016.02.001 Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 1 Cannulation of the diaphragmatic surface of the right ventricle is shown with the outflow attached to the main pulmonary artery (PA). Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 2 The body of the right atrium is cannulated. Felt washers prevent over-insertion of the cannula onto the right atrium. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 3 Standard median sternotomy is performed. After the pericardium is opened, the patient is systemically anticoagulated, the ascending aorta, superior vena cava (SVC), and inferior vena cava (IVC) are cannulated for cardiopulmonary bypass (CPB). Cannulation should be performed near the heart to preserve some virginal aorta, SVC, and IVC for subsequent cannulation at the time of transplantation. Caval tapes may not be necessary if effective vacuum assisted drainage is achieved. Again, this strategy may limit retro-caval scarring that may make the subsequent transplant operation more difficult. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 4 After initiation of cardiopulmonary bypass, the aorta is cross clamped and then divided proximal to the clamp at the level of the sinotublar junction. The main pulmonary artery is divided just above the pulmonic valve. Again, leaving most of the ascending aorta and main PA will facilitate the subsequent transplant procedure. Next, the right and left ventricles are excised approximately 1-2cm distal to the right and left atrioventricular grooves respectively. The dashed line indicates the line of transection of the right and left ventricles. Care is taken to leave a rim of ventricular muscle with the mitral and tricuspid annuli to buttress the sewing ring attachment. PA = pulmonary artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 5 (A) The initial ventricular incision is made parallel to the right AV groove, approximately 1-2cm off of the groove toward the ventricular apex. The transection of the right and left ventricles is facilitated by opening the RV and LV outflow tracts at their anterior most aspect (see dashed lines) . In opening the LV outflow tract, the posterior element of the aortic valve is left in continuity with the mitral annulus which will be attached to the sewing ring. AV = atrioventricular; LV = left ventricle; RV = right ventricle. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 5 (Continued) (B) The heart being lifted to display the posterior AV groove. Again, the posterior and lateral wall of the LV is transected 1-2cm from the posterior AV groove and the coronary sinus. AV = atrioventricular; LV = left ventricle; LA = left atrium. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 5 (Continued) (C) After the free wall of the RV and LV have been transected, the tricuspid and mitral subvalvular apparati must be transected (see dashed lines). The interventricular septum is divided last. Care is again taken to leave ventricular septal tissue around the mitral and tricuspid annuli. LV = left ventricular; RV = right ventricular; TV = tricuspid valve; MV = mitral valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 6 Additional ventricular muscle is resected, along with the subvalvular apparatus on the tricuspid and mitral valves. Care is exercised to maintain a rim of ventricular muscle, as well as the annuli and leaflets of the tricuspid and mitral valves which adds strength to the sewing ring attachment. Residual aorta, aortic valve, main pulmonary, and pulmonic valve are resected. Next, the orifice of the coronary sinus is identified and oversewn with a running Prolene suture through the annulus of the tricuspid valve. The orifice of the left atrial appendage may also be oversewn from inside of the left atrium; however, may result in scarring that affects the subsequent transplant. CS = coronary sinus. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 7 Large pledgetted sutures are passed from the ventricular side to the atrial side. These sutures incorporate the annulus and residual leaflet tissue of the mitral and tricuspid valves. After the sutures have been placed circumferentially around the mitral annulus, they are passed through the sewing ring and tied. The tricuspid annulus is similarly treated. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 8 The sewing rings should be applied so that the sewing ring screw points in a direction that enables easy application of the screw driver. After the sutures are tied, the attachment of the ring to the annulus is carefully inspected and additional sutures are placed as needed. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 9 Next, the HVAD pumps with preattached outflow grafts are inserted into sewing rings and secured by tightening the sewing ring screw with the torque screw driver. Before tightening make sure that the plastic gasket on the HVAD cannula is completely within the sewing ring. If the gasket is still visible, then the pump has not been properly introduced into the sewing ring. The pumps are inserted so that the outflow grafts are directed toward the right side of the patient. Blood volume from the CPB reservoir is used to fill the pumps and after pressurizing the right and left grafts, they are measured to reach the aorta and main pulmonary artery. CPB = cardiopulmonary bypass. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 10 The grafts are cut on a generous bevel and the hoods of these grafts are then anastomosed to the main pulmonary artery and then to the aorta, both of which have a much greater diameter relative to the 10mm graft. A 4-0 Prolene suture with a smaller needle is preferred to reduce bleeding from needle holes. After the grafts are attached and pressurized, the final course is inspected to be certain there is no kinking or potential for obstruction. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 11 The 2 power cords are looped around the pumps and then are tunneled out of the upper abdomen. The power cords are attached to the controllers. Blood volume from the CPB reservoir is used to fill the pumps, the patient is ventilated and both grafts are deaired with an 18 gauge needle. The pumps are activated and the grafts are unclamped. The outflow for the right pump is released first. The patient is weaned from CPB with increasing pump speeds; typical settings are 2000rpm for the right pump and 2800rpm for the left pump. We have not needed to constrict the RVAD outflow graft as some centers have described. Intraoperative transesophageal echocardiography is used to assess the adequacy of deairing; the interatrial septal position is examined and a midline position suggests properly balanced right and left sided support. A pulmonary artery pressure line may also be placed. CPB = cardiopulmonary bypass; RVAD = right ventricular assist device; RV = right ventricle; LV = left ventricle; Ao = aorta; PA = pulmonary artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 12 Final configuration before closure is shown. The power cords encircle the pumps and are tunneled out of the lower aspect of the sternotomy incision through the rectus fascia. The power cord for the right sided device exits the body in the right upper quadrant of the abdomen. The power cord for the left sided device exits the body in the left upper quadrant of the abdomen. Sternal closure may be delayed if there is coagulopathy and bleeding concerns. Before sternal closure, a Gore-Tex membrane can be positioned over the great vessels and outflow grafts to reduce adhesions to the sternum. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 306-321DOI: (10.1053/j.optechstcvs.2016.02.001) Copyright © 2016 Elsevier Inc. Terms and Conditions