Implantation of the Jarvik 2000 Heart O.H. Frazier, Igor Gregoric  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 7, Issue 3, Pages 120-125 (August 2002) DOI: 10.1053/otct.2002.36315 Copyright © 2002 Elsevier Inc. Terms and Conditions

FIG I The Jarvik 2000 left ventricular assist system. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

1 The Jarvik 2000 pump is implanted through a left thoracotomy. The patient is placed in the right lateral decubitus position, at an angle of approximately 45 degrees, with the hips rotated to allow exposure of the left femoral artery for cardiopulmonary bypass cannulation. A left thoracotomy incision is made through the 5th or 6th intercostal space, allowing exposure to the apex of the left ventricle and the descending thoracic aorta. The pericardium is incised longitudinally, avoiding injury to the phrenic nerve. The descending aorta is exposed. Division of the inferior pulmonary ligament may facilitate exposure. To improve the surgical view, the left lung may be collapsed if this does not result in cardiovascular compromise. Anticoagulation is then achieved with intravenous heparin (1 mg/kg). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 Once the descending aorta has been exposed, the 12-mm Hemashield outflow graft (Boston Scientific, Natick, MA) is transected. With the aid of a partial-occlusion clamp, the free portion of the graft is anastomosed to the mid-descending aorta: The aorta is incised longitudinally, and the end-to-side anastomosis is completed with a running 4–0 polypropylene suture. The outflow graft is then clamped, the aortic clamp is released, and pledgeted sutures are used, if necessary, to obtain hemostasis. An additional dose of heparin (2 mg/kg) is then administered, and femoral cannulation is completed. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 The driveline is tunneled through the diaphragm, under the left costal margin, and is pulled through the subcutaneous tissue of the abdominal wall. For this purpose, a 10-mm incision is made in the right upper abdominal quadrant, in the midclavicular line, 5 cm below the costal margin. The subcutaneous tunnel is created with a tunneler, and the chest tube-driveline is pulled through. The Jarvik pump is placed in position, and the length of the driveline needed to exit the chest wall is estimated. A strain-relief loop must be created in the thoracic cavity to allow for movement of the abdominal cable as the heart contracts. Once the driveline has been tunneled, the abdominal cable can be connected in preparation for starting the pump. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 The next step involves attaching the Silastic sewing ring to the apex of the heart. This is done with an interrupted, pledgeted 2–0 Ethibond suture (Ethicon, Somerville, NJ). The sewing ring is positioned about 2 cm lateral to the left anterior descending artery, on the apex of the heart. To allow proper positioning of the Jarvik pump on insertion, the bevel of the sewing ring must be oriented toward the aortic valve position. During attachment, the shape of the sewing ring is maintained by a hard inner plastie ring, which should be kept in place until the pump is ready for insertion. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

5 After the sewing ring has been secured, femoral cannulation for cardiopulmonary bypass is completed, and the patient is placed in the Trendelenburg position. Transesophageal echocardiography should be available for intraoperative cardiac assessment and to aid in the de-aeration process. Once cardiopulmonary bypass has begun, the heart is fibrillated with an external epicardial fibrillator. A scalpel is then used to make an incision through the myocardium inside the sewing ring. The myocardium is cored with an obturator coring knife. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

6 The coring knife is inserted into the ventricular cavity and is then twisted while being pulled outward. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

7 After the full-thickness myocardial plug has been removed, the pump is inserted into the ventricle. It is secured through the sewing ring with 2 umbilical tapes. Before the tapes are tightened, the pump is rotated to ensure proper positioning of the electrical wires and outflow graft. The heart is defibrillated, and weaning from cardiopulmonary bypass is initiated. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions

8 Once the correct length and orientation of the outflow graft have been obtained, the 2 grafts are anastomosed end-to-end with 5–0 polypropylene sutures. The graft is de-aired with a 19-gauge needle, and the pump is then started at 8,000 revolutions per minute (the minimal speed setting). Cardiopulmonary bypass is discontinued. Hemodynamic assessment is performed with transesophageal echocardiography, a pulmonary artery catheter, an arterial pressure line, and a 16-mm ultrasonic flow probe on the pump's outflow graft. This flow probe is removed before the thoracotomy incision is closed. Once proper functioning of the Jarvik 2000 heart has been confirmed, the cannulation sites are closed routinely. Thoracic hemostasis is obtained, chest tubes are inserted, and the thoracotomy incision is closed in the normal fashion. The driveline is secured with a 0–0 polypropylene suture. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 120-125DOI: (10.1053/otct.2002.36315) Copyright © 2002 Elsevier Inc. Terms and Conditions