How I Do It: Total Artificial Heart Implantation

To begin, a standard median sternotomy was performed and both pleural spaces are widely opened. The anterior diaphragmatic attachments at the pericardium were taken down. The phrenic nerve was identified on the left side. The caudal aspect of the left sided pericardium was taken down to within a few centimeters of the phrenic nerve.

Prior to the initiation of cardiopulmonary bypass, the external driveline exit sites were identified and marked approximately 10 centimeters below the left subcostal margin. The driveline sites were approximately 5 centimeters apart. A silk suture was placed in the middle of each site and a small circle of tissue was excised down to the fat layer. A tunnel to the chest was then created, utilizing blunt dissection with a tonsil. The drivelines were either placed and the pumps were pulled out of the chest, wrapped in a sterile blue towel, and affixed to the drape with a clamp. If this is not feasible, then a strip of Esmark tape should be passed through each tunnel to maintain the tunnel.

Purse-string sutures were then placed in the ascending aorta near the innominate origin, superior vena cava, and inferior vena cava. Then, systemic heparin was administered. Once the ACT was over 400, the patient was cannulated and placed onto cardiopulmonary bypass. An antegrade cardioplegia line was placed in the ascending aorta. The aortic cross clamp was placed and cold antegrade cardioplegia was delivered. A vent was then placed across the left atrium if an atrial septal defect is present.

The ventriculectomy was then performed. The right ventricle was incised, beginning with the right ventricular outflow tract below the pulmonary valve annulus. The incision was extended 3 to 5 millimeters below and ran parallel to the tricuspid valve annulus around to the posterior interventricular septum. The tricuspid valve chordae were disconnected and the apex of the left ventricle was excised. The incision at the apex of the left ventricle was extended cephalad to 3 to 5 millimeters from the mitral valve annulus parallel to the ventricular septum. The incision extended 3 to 5 millimeters parallel to the mitral valve annulus around to the posterior septum and connected to the initial incision. The aorta and main pulmonary artery were circumferentially mobilized. The main pulmonary artery and aorta were transected cephalad to the sinotubular junctions. Then, the ventricular septum was excised, the pulmonary valve was excised, and the aorta was opened longitudinally. The atrioventricular valve leaflets were trimmed within 3 to 5 millimeters of annulus. Both the mitral and tricuspid valve annuli were inspected thoroughly.

The atrial cuffs were then prepared. The orifice of the left atrial appendage was identified and oversewn through the mitral valve with a dual-layer continuous 4-0 polypropylene suture. The coronary sinus was identified and oversewn through the tricuspid valve with a dual-layer continuous 5-0 polypropylene suture. The atrial septal communication (if present) was closed with a continuous 5-0 polypropylene suture. The atriotomy was subsequently closed with a continuous 5-0 polypropylene suture.

The inflow connectors (Quick Connects) were prepared prior to the initiation of the cardiopulmonary bypass. The inflow connectors were trimmed circumferentially leaving 3 millimeters of cuff. The inflow connectors were then inverted and placed in the atria. The inflow connectors were secured to an atrial cuff including the valve tissue, annuli, and the outer atrial rim with a continuous 3-0 polypropylene with a large needle. The bites were closely spaced to avoid that there were no folds created in the cuffs. The suture line along the septum should pass through both inflow connector cuffs. The dual-layer suture line along the interventricular septum ensured adequate hemostasis and device stability. The cuffs were then inverted back to their original position once in place. Any folds in the outer or inner perimeter in both atrial cuffs were identified and repaired. The inflow connector suture lines were then pressure tested. Heavy needle drivers were placed at the 10 and two o’clock positions on cuff to aid in seating the pressure testing plug appropriately. The back lip of the pressure tester was seated along the posterior edge of the cuff. The needle holders will pull the cuff over, while simultaneously pulling the cuff apart, to seat the anterior edge of the testing plug. The cardiac mass was surrounded by surgical sponges and surgical adhesive was applied to the outer perimeter of the inflow connectors. Extreme care was taken to ensure that no adhesive entered inside the inflow connectors and atria.

The outflow grafts were then pre-treated with CoSeal. The grafts were stretched, measured, and trimmed to size. The pulmonary artery outflow graft was trimmed to 6 centimeters. The aortic outflow graft was trimmed to 3 centimeters. The pulmonary outflow graft anastomosis was completed with a bovine pericardial strip to use as a buttress and a continuous 4-0 polypropylene. The aortic outflow graft anastomosis was also completed with a bovine pericardial strip to use as a buttress and a continuous 4-0 polypropylene. Both the pulmonary artery and aortic outflow grafts were pressure tested, and leaks were identified. Again, heavy needle drivers were placed at the 10 and two o’clock positions on the cuff to aid in properly seating the pressure test plug.

Prior to device placement, the left side of the expanded polytetrafluoroethylene membrane was placed. Silk counter traction sutures were placed on the two corners of one side of the membrane. A series of simple interrupted polypropylene sutures were placed along the opposite edge and then were secured to the left side of the pericardium at the level just above the pulmonary veins. The process was repeated along the diaphragmatic surface and right side with an additional membrane placed on the anterior surface. Esmark polyisoprene tape encircled the great vessels and cavae to aid with re-entry at the time of transplant.

The device was brought on to the field and connected to the inflow and outflow connectors. The order of connections is as follows:

1. Left atrium
2. Aorta
3. Right atrium
4. Pulmonary artery

The device ventricles were de-aired and the patient was placed in a steep Trendelenburg position. The aortic root vent was placed in the native ascending aorta. The driver pumps were slowly turned on and the surgeon agitated the ventricles to de-air. The transesophageal echocardiogram ultimately confirmed complete evacuation of air. The driver speeds were slowly increased, and the aortic cross-clamp was removed. The patient was gently weaned and separated from the cardiopulmonary bypass. Meticulous mediastinal hemostasis was conducted and the chest wall was thoroughly inspected. The anterior ePTFE membrane encasing the device was secured to the right and left membranes. The chest was closed with double stainless steel wires and the incision was closed in layers. The patient was then transferred to the cardiac intensive care unit.

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