The Jarvik-2000 ventricular assist device implantation: how we do it

Abstract

The Jarvik-2000 is a non-pulsatile axial-flow left ventricular assist device (LVAD) that is largely used in patients who present in end-stage heart failure, as a bridge to transplant support or destination therapy. From its first utilization, several implantation techniques have been elaborated, starting from a median sternotomy with cardiopulmonary bypass (CPB) support and moving towards a minimally invasive access with an off-pump strategy. Here we present the favored surgical technique used in our department to implant the Jarvik-2000, in a step-by-step fashion.

Keywords: Jarvik; implantation; off-pump; technique.

Figure 1

Median full sternotomy skin incision.

Figure 2

Left lateral extended thoracotomy skin incision for the mediastinal access, with additional incisions on the shoulder, neck and retroauricolar area for the driveline tunneling and skull pedestal implantation.

Figure 3

Left lateral mini-thoracotomy and upper mini-sternotomy skin incisions.

Figure 4

Implantation of the Jarvik pump into the left ventricular apex with distal outflow graft conduit anastomosis to ascending aorta.

Figure 5

Implantation of the Jarvik pump into the left ventricular apex with distal outflow graft conduit anastomosis to descending thoracic aorta.

Figure 6

Retroauricolar broad-base C-shape flap incision.

Figure 7

(A) Subcutaneous tissue is dissected in order to expose the mastoid bone. The periosteum is scraped (generally in four slices) in order to receive the pedestal and cover it after its implantation to promote bony apposition and a faster recovery; (B) six holes are drilled in the bone for the fastening screws of pedestal. The three-pin connector exits the skin from the latero-cervical subcutaneous tunnel.

Figure 8

(A) The pedestal plug is mounted and fixed on the bone with the three-pin connector inside it. Self-tapping screws are utilized to allow a 1.5 mm safety-margin to prevent skull penetration; (B) cutaneous retroauricolar flap is repositioned and the pedestal exits across the skin (the area is punched out for receive the connector and let it get through the skin layer).

Figure 9

Sewing ring positioning onto the apex. It is sutured and tied to the myocardium using 10-12 interrupted pledgeted, double-armed 3-0 polypropylene sutures.

Figure 10

Outflow graft conduit of the pump is tunneled from the left thoracotomy toward the upper sternotomy in order to connect the apex and the ascending aorta. The conduit runs below the pericardium. In this picture, the surgeon’s hand holds the Jarvik-2000 before its apical implantation.