1. Implantation of the MicroMed DeBakey VAD
George P. Noon, Matthias Loebe, Suellen Irwin, Javier A. Lafuente 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 7, Issue 3, Pages (August 2002)
DOI: /otct
Copyright © 2002 Elsevier Inc. Terms and Conditions

2. 1A
A small abdominal wall pocket is formed below the rectus muscle. For pump implantation, a median sternotomy incision is performed extending several inches below the xiphoid process. A small abdominal wall pocket is formed below the rectus muscle. The size and configuration of the pocket is determined by using the actual or mock pump as a model. To provide access to the left ventricular apex, the pericardium is opened, the diaphragmatic attachment to the costal margin is divided, and both are extended laterally beyond the apex. Meticulous hemostasis is obtained.1–4 Aprotinin may be administered per physician preference. The patient is heparinized in preparation for cardiopulmonary bypass. The ascending aorta is cannulated, and then single or double cannulation of the right atrium and cava is performed, depending on presence of a patent foramen ovale. If a patent foramen ovale is detected by echocardiogram, it is repaired before beginning the LVAD implant.1–4
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

3. 1B
A left thoracotomy extending across the costal margin is used for exposure of the left ventricular apex and descending thoracic aorta in the thoracic implant. Using this approach, the patient is placed in a lateral position with the left side up. Double-lumen intubation is preferred. The left groin is prepared for exposure of the common femoral artery and vein for cardiopulmonary bypass cannulation. A left anterior-lateral thoracotomy skin incision is performed, and the chest cavity is entered through the sixth or seventh intercostal space and extended across the costal margin. The left lung is collapsed, and the left ventricular apex is exposed by incising the pericardium. The descending aorta is exposed above the diaphragm, and the inferior pulmonary ligament is divided. The upper part of the descending aorta can be used if desired for arterial cannulation for extracorporcal circulation.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

4. 2A
Cardiopulmonary bypass is initiated and preparation for post-implant right heart bypass is performed if indicated with cannulation of the pulmonary artery.7 The left ventricular apex is elevated, and the insertion site of the inflow cannula is selected. The apical fixation ring is sewn in place with interrupted 2–0 or 3–0 polypropylene mattress sutures with large Teflon felt pledgets.1–4 Four of the fixation ring sutures are tied at equal spaces apart to hold the ring in place. The remaining sutures are left untied. and all are clamped separately in preparation for sewing to the inflow cannula sewing ring.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

5. 2B
The pump inflow cannula is inserted in the left ventricular apex and sewn into place. Then 2–0 or 3–0 pledgeted polypropylene sutures are placed in the left ventricular apex to attach the fixation ring in the usual fashion. The device is assembled, and a vascular clamp is applied on the outflow graft. Heparin is administered, and the patient is cannulated and placed on cardiopulmonary bypass. The core is removed from the apex, and the device inflow cannula is inserted into the left ventricle. Again, care is taken to obtain correct positioning of the inflow cannula. The cannula is secured using the previously described technique. The device is deaired by removing and reapplying the vascular clamp from the outflow graft. If the heart is fibrillating it is defibrillated.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

6. 3A
In preparation for insertion of the pump inflow cannula, the left apex is maintained elevated. The heart may remain beating, fibrillated, or arrested. Using a scalpel with a no. 11 blade, a full-thickness cruciate incision is made inside the apical ring. The ventricular apex is manually compressed to prevent bleeding. A round bladed coring device is inserted into the left ventricle to extract a core of the left ventricular apex. Coring of the apex can also be performed using a scalpel and scissors. To confirm precise apical coring and extraction, the apical tissue is removed from the coring device and carefully examined for completeness. Digital ventricular exploration is performed to evaluate the position of the core and to ensure absence of any potential obstruction to inflow. Visual exploration of the ventricle using pump suction to evacuate blood may be necessary for further removal of myocardium or clot.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

7. 3B
A partial occlusion clamp is placed on the descending aorta. The vessel is opened longitudinally, and the outflow graft is cut to appropriate length usually with a gentle curve, and if necessary, a portion of the external graft protector is removed. It is important to make certain that there is adequate perfusion and oxygenation of the upper body while the aorta is partially clamped. The graft is sewn end-to-side to the aorta using 4-0 running polypropylene suture. The heart is filled with blood, and the device is again carefully de-aired. The partial occluding aortic clamp is removed, and the VAD is started. Meticulous hemostasis is obtained. The driveline is tunneled to the right side of the abdomen where it exits through the skin. The pump is connected to the controller and CDAS (Clinical Data Acquisition System) and started.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

8. 4A
The pump outflow graft is clamped, and the inflow cannula is inserted into the left ventricular apex.1-4 The 2 purse-string sutures on the apical fixation ring are tied. Proper placement of the inflow cannula inside the ventricle is imperative. The goal is to place the inflow cannula so that it is angled toward the aortic valve without being directed toward the septum or free wall of the myocardium. The inflow cannula position can be adjusted by moving the body of the pump in the pocket. The cannula opening must be clear of any ventricular tissue. Using the previously placed polypropylene sutures, the suture ring on the inflow cannula is sewn to the apical fixation ring.1-4 The pump and left ventricle are de-aired by allowing the ventricle to fill with blood. The pump and outflow graft are elevated and filled with blood from the ventricle by releasing and reapplying the clamp on the outflow graft. The apical insertion site is carefully checked for bleeding. To ensure hemostasis, it may be necessary to further seal the ventricular sewing ring attachment by approximating the left ventricular apex and the sewing ring with a Teflon felt strip and continuous 2-0 or 3-0 polypropylene suture. Biological glues may also be applied.1-4
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

9. 4B
The pump and outflow graft are covered with ePTFE to facilitate subsequent transplant and device removal. The patient is weaned from cardiopulmonary bypass; heparinization is reversed with protamine sulfate; and 2 chest tubes are inserted into the left chest. The device is covered with ePTFE, and the thoracotomy incision is closed in the usual fashion.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

10. 5
The MicroMed DeBakey VAD is placed into the abdominal pocket, and the length of the outflow graft is measured and trimmed. The graft should lie under the right sternal border without kinking or overstretching. A proximal, external graft protector is designed to prevent graft kinking. Care is taken to ensure that the flow probe is approximated to the end of the graft protector as this helps in proper positioning of the outflow graft. It may be necessary to create a subcostal pocket on the right to facilitate graft positioning. A trocar is tunneled from the abdominal wall pocket across the midline to exit through the skin in a convenient position above the right iliac crest. The surgeon may slightly bend the trocar to ease the passage across the abdomen. After exiting the skin, the driveline is connected to the trocar and pulled through the exit site. The trocar is removed, and the driveline is connected to the controller.1-4
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

11. 6
For the aortic anastamosis, a partial occlusion clamp is placed on the ascending aorta. A longitudinal arteriotomy is made, and the outflow graft is sewn to the lateral ascending aorta using 5-0 polypropylene suture. After completion of the anastamosis, an 18-gauge needle is placed in the outflow graft between the aortic anastomosis and graft clamp. By temporarily releasing the aortic partial occlusion clamp, the distal aortic graft is filled with blood and trapped air escapes through the 18-gauge needle. The aorta is re-clamped and remaining air in the system is released through the 18-gauge needle by unclamping the proximal outflow graft and intermittently starting and stopping the pump.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

12. 7
The aortic partial occluding clamp is then removed and continuous pumping is begun at 7,500 rpm. After completing deairing, the 18-gauge needle is removed, and a pledgeted 4-0 polypropylene suture is used to oversew the needle hole.1-4 Pump flows are begun at 7,500 rpm and adjusted to maintain a cardiac index of approximately 2.0 L/min/m2 or greater. To maintain sufficient pump flow, it is important to ensure adequate preload. Hypovolemia and excessive pump speed could result in ventricular collapse, diminished flows, and suction of air. Using echocardiography, the location of the inflow cannula is viewed and the ventricles are assessed for volume, function, and air. The inflow cannula must be free of obstruction. When placement of the cannula is noted to be satisfactory and flows are adequate, the patient is weaned from cardiopulmonary bypass and protamine is administered to reverse heparinization. If needed, temporary right heart bypass through the pulmonary artery vent line can be instituted before completely weaning off cardiopulmonary bypass.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions

13. 8
After meticulous hemostasis, 1 or 2 drains are placed in the mediastinum and 2 drains are placed in the pump pocket and posterior pericardium.1-4 The device is covered with Preclude Pericardial Membrane (ePTFE) (WL Gore and Associates, Inc, Flagstaff, AZ) to facilitate subsequent exposure and protect the graft and heart at the time of transplantation. The incision is closed, and the driveline exit site is approximated and the line secured in place with a suture.
Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, DOI: ( /otct )
Copyright © 2002 Elsevier Inc. Terms and Conditions