James A. Magovern, David M. Lasorda

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Implantation of the TandemHeart Percutaneous Left Ventricular Assist Device James A. Magovern, David M. Lasorda Operative Techniques in Thoracic and Cardiovascular Surgery Volume 7, Issue 3, Pages 112-119 (August 2002) DOI: 10.1053/otct.2002.35527 Copyright © 2002 Elsevier Inc. Terms and Conditions

1 The photograph shows the TandemHeart pump, which is a small centrifugal pump driven by an electromagnetic motor. On a mock loop, the device can flow up to 10 L/min, but in the clinical setting, the average flow is 3 to 4 L/min owing to limitations from cannula size. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 The photograph shows the pre-curved transeptal cannula (right), the obturator for the cannula (middle), and the 2-stage dilator (left) that is used to enlarge the transeptal puncture site. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 The photograph shows the needle, wire, dilators, and 15-F arterial cannula used to cannulate the femoral artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 The photograph shows the pump controller, which stands adjacent to the patient bed. The unit is small, compact, and transportable. It also has a built-in back-up unit for use in the case of controller failure. The controller regulates pump speed, the lubrication system, and alarm functions. Operation of the unit is quite simple, consisting of a dial to increase or decrease the revolutions per minute. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

5 The schematic drawing shows the unique fluid seal that distinguishes this pump from other centrifugal pumps. The lubrication line (yellow) delivers 10 mL/h of heparinized sterile water into the pump, which floats the impeller on the rotor and provides a liquid seal between the upper and lower housing. The delivery of heparinized fluid also allows local anticoagulation within the pump. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

6 Placement of the transeptal cannula begins with accessing the right femoral vein percutaneously. Then a 0.032 “J-tip guidewire is advanced to the superior vena cava. A Mullins sheath/catheter is advanced over the wire. The guidewire is removed, and a Brockenbaugh transeptal needle is advanced through the catheter (not extending beyond the tip of the catheter). The sheath/catheter/needle are pulled back into the right atrium until the fossa ovale is engaged. Echocardiography is also helpful in confirming engagement of the fossa with the transeptal needle. (The drawing shows a 4-chamber view of the heart with the transeptal needle pushing the fossa ovale toward the left atrium.) The needle followed by the catheter and sheath are advanced through the fossa ovale into the left atrium. The position in the left atrium can be confirmed by measuring pressure and injecting contrast dye through the sheath. After satisfactory position has been demonstrated, the transeptal needle and catheter are removed, leaving the sheath in the left atrium. Then, a long Toray wire is advanced through the sheath into the left atrium and the sheath is removed. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

7 At this point, a looped wire is present in the left atrium, which is shown in the drawing. A graduated 2-stage dilator (14 to 21-F) is then advanced over the wire to dilate the septal puncture site. Next, a 21-F venous cannula is passed over the wire and positioned in the left atrium. The arterial return cannula is inserted into the common femoral artery using the Seldinger technique. Either the right or left side can be used. If a smaller return cannula is necessary because of concerns about distal leg ischemia, two 10-F cannulas can be inserted, one in each femoral artery (not shown). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions

8 The drawing shows a patient with the complete system in place. The transeptal cannula can be seen extending from the right femoral vein to the right atrium, and then entering the left atrium. The arterial cannula is also shown in the right femoral artery. The blood pump is attached with a Velcro mechanism to a circumferential bandage around the patient's thigh. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 112-119DOI: (10.1053/otct.2002.35527) Copyright © 2002 Elsevier Inc. Terms and Conditions