1. Beating Heart DeBakey VAD Implantation - the Muenster Technique Dieter Hammel, Christof Schmidt*, Christof Schmid, Markus J. Wilhelm, Mario C. Deng & Hans H. Scheld Depts. of Cardiothoracic Surgery & Anesthesiology* Westfalian Wilhelms-University of Muenster Muenster, Germany

2. “Beating Heart” - Implantation Sternotomy & device pocket CPB (PFO exclusion or repair) connection to apex Device & driveline placement Aortic anastomosis De-Airing Weaning & chest closure

3. Sternotomy & Device Pocket Sternotomy Rectus sheath preparation M. transversus dissection Xiphoid resection

4. Diaphragm Dissection Pericardial incision Enbloc-incision of diaphragm & pericardium (2 x GIA 75mm) Re-adaptation of diaphragm & M. transversus (Vicryl-sutures)

5. Cannulation, PFO Exploration Aortic cannulation Digital exploration of the atrial septum via the venous pursestring suture PFO closure if mandatory CPB initiation

6. Apex Anastomosis I LV apex elevation 8 Ethibond (3-0 MH) sutures with 2 teflon felt strips (circular) 4 of 8 knots of apical fixation ring

7. Apical incision Excision of the LV apex -> coring device Removal of additional tissue / thrombus from the LV apex Apex Anastomosis II

8. Inflow cannula insertion Suturing of inflow cannula suture ring to the apical fixation ring (Ethibond) Final running suture (3-0 Prolene) between felt strips and inflow cannula suture ring Apex Anastomosis III

9. Tension free device positioning (pocket size !) Graft protector wrapping with a 22 mm PTFE prosthesis De-airing via a large vent Device Placement & Outflow Wrapping

10. Skin incision in the lower right quadrant Preparation of a subcutaneous tunnel using a sponge forceps for trocar protection Driveline Tunneling

11. Aortic Anastomosis Measuring of the outflow graft length End-to-side anastomosis (4-0 Prolene, delayed tying for adequate deairing) CVP  by CBP & pump start (start NO inhalation)

12. Weaning from CBP & Outflow graft wrapping II Weaning Wrapping of distal outflow graft with remainder of PTFE prosthesis Drainage and chest closure as usual