1. Implantation of a Durable Left Ventricular Assist Device: How I Teach It 
John M. Stulak, MD, Ashraf Abou El Ela, MD, Francis D. Pagani, MD, PhD 
The Annals of Thoracic Surgery 
Volume 103, Issue 6, Pages (June 2017)
DOI: /j.athoracsur
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Common durable implantable left ventricular (LV) assist devices used in clinical practice. The HeartMate II (Abbott Laboratories, Abbott Park, IL) is a continuous-flow pump with axial design positioned within a preperitoneal pump located below the diaphragm. The HeartMate 3 (Abbott Laboratories) and HVAD (Medtronic, Inc, Minneapolis, MN) are continuous-flow pumps with centrifugal design and have an integrated inlet cannula that inserts directly into the LV apex that permits positioning within the pericardial sac.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
The preperitoneal pocket is created by dissection of the preperitoneal layer from the abdominal wall. The creation of the preperitoneal pocket is specific to the HeartMate II device (Abbott Laboratories, Abbott Park, IL), where the pump is positioned within the preperitoneal location below the diaphragm. The inflow cannula of the pump crosses from the preperitoneal pocket through the diaphragm to insert into the left ventricular apex.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
The percutaneous lead is tunneled through the right rectus sheath and exits just below the costal margin at the anterior axillary line.
(Reprinted from Romano MA, Haft J, Pagani FD, HeartWare HVAD: principles and techniques for implantation, Oper Tech Thorac Cardiovasc Surg, 2013;18:230–8, with permission from Elsevier.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
The Foley catheter is inserted into the apex of the left ventricle. The apical cuff of the HVAD device (Medtronic, Inc, Minneapolis, MN) is sewn to the apex of the left ventricle using 4 sutures of 2-0 Ethibond (Ethicon, Somerville, NJ) placed in an interrupted, pledgetted, horizontal mattress fashion. A running suture of 4-0 Prolene around the cuff is then performed for hemostasis (not shown).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
Coring of the left ventricle apex for the HVAD device (Medtronic, Inc, Minneapolis, MN) is performed.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
The outflow graft is sewn to the ascending aorta, and the outflow graft is positioned within the pericardial space.
(Reprinted from Romano MA, Haft J, Pagani FD, HeartWare HVAD: principles and techniques for implantation, Oper Tech Thorac Cardiovasc Surg, 2013;18:230–8, with permission from Elsevier.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

8. Fig 7
The outflow graft is covered with native pericardium, and the percutaneous lead (driveline) is covered with preperitoneal fat to facilitate sternal reentry at the time of transplant or device exchange.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions