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Eur J Cardiothorac Surg 2002;21:546-548
© 2002 Elsevier Science NL

How-to-do-it

Implantation of the permanent Jarvik-2000 left-ventricular-assist-device: surgical technique

^a Department of Cardiovascular Surgery, University of Freiburg, Hugstetterstrasse 55, 79106 Freiburg, Germany
^b Texas Heart Institute, Houston, TX, USA

Received 4 October 2001; received in revised form 10 December 2001; accepted 14 December 2001.

* Corresponding author. Tel.: +49-761-270-6138; fax: +49-761-270-2550
e-mail: misegenth{at}aol.com

	Abstract

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
The Jarvik-2000 is an axial-flow left-ventricular-assist-device (LVAD) designed for permanent use. The power supply is provided by a cable plugged into a skull-pedestal mounted in the retro-auricular area. We describe the surgical technique and discuss potential and encountered problems.

Key Words: Jarvik-2000 • Left-ventricular-assist-device • Surgical technique • Heart failure

	1. Introduction

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
The Jarvik-2000 (Fig. 1 ) is the first of the new-generation axial-flow left-ventricular-assist-devices (LVADs) designed for permanent use [1]. Common problems of conventional LVADs are bleeding, infection, and thrombo-embolic events [2]. The Jarvik-2000 offers several advantages to potentially reduce complications: limited surgical dissection, left thoracotomy [3], absence of an inflow-cannula, minimal foreign material, no fixation of the cardiac apex, no pseudo-capsule, anastomosis to the descending aorta, and extensive clinical experience with skin exit-sites from cochlear implants [4]. We present our technique for implantation of the permanent Jarvik-2000 based on four implants of this system without major complications, reoperations, or mortality.

View larger version (82K): [in this window] [in a new window]   Fig. 1. The Jarvik-2000 (right) with open titanium-case (left), exposing the impeller and the electrical coils. Note the metal power-connection and outflow-elbow. The inset shows the sewing-ring, the black lines illustrate the asymmetry.

	2. Pre-operative evaluation

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

In addition to a work-up for heart transplantation [6], a computerized tomography (CT) of the chest and head is performed to allow site-selection of the outflow-graft anastomosis as well as for the skull-pedestal in an area with thick bone, at least 5 mm.

	3. Operative procedure

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
The patient is positioned for a left thoracotomy. Nitric oxide and aprotinin are used routinely [7,8]. The surgical field includes the left groin and temporo-occipital area, drapes are secured to the skin.

	4. Skull pedestal for power supply

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
The skin exit-site is punched-out. The corresponding site on the skull is marked. A broad-based, curvilinear incision is performed. Periosteal-flaps are elevated. The outer table is leveled for stable seating of the pedestal. The power-cable is tunneled from the chest and connected to the pedestal. The cable is placed in a zigzag fashion using two incisions, allowing neck motion without strain on the cable. Self-tapping screws anchor the pedestal, allowing a 0.5-mm safety-margin to prevent skull penetration. Additional burr-holes and pedestal coverage with periosteum promote bony ingrowth. Pedestal-implantation by a head-and-neck surgeon expedites the procedure.

	5. Implantation of the Jarvik-2000

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
The left femoral vessels are exposed. A standard left-posterolateral thoracotomy is performed entering the sixth or seventh intercostal-space for dilative disease, the fifth for normal-sized hearts. The Jarvik-2000 is placed in the thoracic cavity, protected with a sterile glove and towels. The power cable is brought out through the second intercostal-space, between the medial border of the scapula and the spine. The skull-pedestal is mounted. Head-and-neck incisions are closed. In partial occlusion without Heparin, an end-to-site anastomosis of the 16-mm outflow-graft to the descending thoracic aorta is sewn using 4-0 Prolene (Ethicon Inc., Norderstedt, Germany) on a V-6 needle with felt-strip reinforcement (Fig. 2a ). It is important to place the clamp with distal pulses maintained. The outflow-graft is clamped directly at the anastomosis. The pericardium is incised horizontally on both sides of the phrenic-nerve to allow good pericardial drainage. Complete hemostasis is achieved before heparin is administered. On femoro-femoral bypass, the cardiac-apex is elevated and vented if necessary. The position of the sewing-ring is marked with electrocautery. The asymmetrical sewing-ring allows placement slightly lateral to the apex, pointing the device away from the septum toward the left-ventricular-outflow-tract. To reduce bleeding complications, we prefer to take deep muscular bites entering and exiting the epicardium using plegetted 2-0 Ethibond-sutures (Ethicon Inc., Norderstedt, Germany) on atraumatic V-7 or MH needles (Fig. 2b). The heart is fibrillated. A special coring-knife is inserted through a cruciate incision. A myocardial core and muscular debris are removed. The Jarvik-2000 is inserted into the left-ventricular cavity and secured to the ring. The device is rotated to avoid rubbing of the power-connection or outflow-elbow (Fig. 1) against the rib-cage or diaphragm. After defibrillation, the heart is slowly filled with the apex elevated and continuous venting of the clamped outflow-graft. The Jarvik-2000 is started. Complete de-airing is confirmed by TEE before unclamping the outflow-graft. Cardiopulmonary bypass is terminated. Heparin reversal and meticulous hemostasis are followed by a standard thoracotomy-closure.

View larger version (92K): [in this window] [in a new window]   Fig. 2. (a) The outflow-graft is sewn to the descending thoracic aorta. Note: the pericardium is opened on both sides of the phrenic nerve for better drainage. (b) The asymmetrcal sewing-ring is sewn to the left ventricular apex. Note: the ring is secured before removing a myocardial core of the left-ventricular apex.

	6. Post-operative care

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

	7. Potential and encountered problems

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
These often cachectic patients are at increased risk for skin breakdown. Determination of the pedestal position aided by CT-scanning is of utmost importance to avoid intracranial hemorrhage. We recommend testing the device after tunneling the power-cable. Significant blood loss in the drapes with ensuing coagulopathy can result if the cable exit-site is left open during cardiopulmonary bypass. Clamping of the outflow-graft at the anastomosis avoids clot-formation before heparin is given. Complete clamping of the descending thoracic aorta precludes femoral bypass in case of sudden need. Hemostasis is of utmost importance as bleeding increases the risk of right-ventricular failure and infection [8]. De-airing with the outflow-graft unclamped allows the femoral cannula to blow air into the head vessels. Good patient selection, attention to details, and a multidisciplinary approach increase the likelihood of good outcomes.

	8. Summary

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 
We have presented our technique of implantation of the permanent Jarvik-2000 LVAD using left-lateral thoracotomy and femoral bypass, with a power-connector in the retro-auricular area. We emphasized attention to details and made suggestions to avoid surgical complications.

	Acknowledgments

 
We wish to thank Drs R. Jarvik and T. Doenst for the valuable suggestions in preparing the manuscript.

	Footnotes

 
The authors have no financial relationship with any of the presented content or investigational devices.

	References

Top Abstract 1. Introduction 2. Pre-operative evaluation 3. Operative procedure 4. Skull pedestal for... 5. Implantation of the... 6. Post-operative care 7. Potential and encountered... 8. Summary References

 

1. Westaby S., Banning A.P., Jarvik R., Frazier O.H., Pigott D.W., Jin X.Y., Catarino P.A., Saito S., Robson D., Freeland A., Myers T.J., Poole-Wilson P.A. First permanent implant of the Jarvik 2000 Heart. Lancet 2000;356:900-903.[Medline]
2. Frazier O.H., Rose E.A., Macmanus Q., Burton N.A., Lefrak E.A., Poirier V.L., Dasse K.A. Multicenter clinical evaluation of the HeartMate 1000 IP left ventricular assist device. Ann Thorac Surg 1992;53:1080-1090.[Abstract]
3. Pasic M., Bergs P., Hennig E., Loebe M., Weng Y., Hetzer R. Simplified technique for implantation of a left ventricular assist system after previous cardiac operations. Ann Thorac Surg 1999;67:562-564.[Abstract/Free Full Text]
4. Parkin J.L. Percutaneous pedestal in cochlear implantation. Ann Otol Rhinol Laryngol 1990;99:796-800.[Medline]
5. Oz M.C., Goldstein D.J., Pepino P., Weinberg A.D., Thompson S.M., Catanese K.A., Vargo R.L., McCarthy P.M., Rose E.A., Levin H.R. Screening scale predicts patients successfully receiving long-term implantable left ventricular assist devices. Circulation 1995;92:II169-II173.
6. Costanzo M.R., Augustine S., Bourge R., Bristow M., O'Connell J.B., Driscoll D., Rose E. Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. Circulation 1995;92:3593-3612.[Abstract/Free Full Text]
7. Argenziano M., Choudhri A.F., Moazami N., Rose E.A., Smith C.R., Levin H.R., Smerling A.J., Oz M.C. Randomized, double-blind trial of inhaled nitric oxide in LVAD recipients with pulmonary hypertension. Ann Thorac Surg 1998;65:340-345.[Abstract/Free Full Text]
8. Goldstein D.J., Seldomridge J.A., Chen J.M., Catanese K.A., DeRosa C.M., Weinberg A.D., Smith C.R., Rose E.A., Levin H.R., Oz M.C. Use of aprotinin in LVAD recipients reduces blood loss, blood use, and perioperative mortality. Ann Thorac Surg 1995;59:1063-1067.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Siegenthaler, M.P. Articles by Beyersdorf, F. Search for Related Content PubMed PubMed Citation Articles by Siegenthaler, M.P. Articles by Beyersdorf, F. Related Collections Mechanical Circulatory Assistance