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Implantations of left ventricular assist devices (LVADs) for mechanical circulatory support have increased over the last decade. These LVADs are used not only for bridge-to-transplantation but also frequently for destination therapy. The technology of the modern-generation LVAD with centrifugal pumps has reached a state where technical malfunctions are rather the exception, even when running for more than 6-8 years. The incremental improvements in clinical outcomes using such pumps have led to a worldwide increase in implantation procedures in different patient cohorts. In this article, the surgical implantation technique for the latest-generation of intrapericardial, fully magnetically levitated centrifugal continuous-flow LVADs is described in detail for the HeartMate 3 system. Each step is illustrated by several sketches and surgically important steps are discussed.

In a porcine model, we investigated the impact of sudden stent graft occlusion of thoracic intercostal arteries after open lumbar segmental artery (SA) ligation.After randomization into two groups, 20 juvenile Yorkshire pigs (27.1±0.6 kg) underwent open lumbar SA sacrifice (T13-L5) followed by endovascular coverage of all thoracic SAs (T4-T12) at 32°C, either in a single operation (group 1) or in two stages separated by seven days (group 2). Collateral network pressure (CNP) was monitored by catheterization of the SA L1, and postoperative hind limb function was assessed using a modified Tarlov score.The CNP in group 1 decreased to 34% of baseline, whereas CNP after lumbar SA ligation in group 2 fell to 55% of baseline (74±2.4 to 25±3.6 mm Hg vs 74±4.5 to 41±5.5 mm Hg; p0.0001). Subsequent thoracic stenting (group 2) led to another significant but milder drop (p=0.002 versus stage 1) from the restored CNP (71±4.2 to 54±4.9 mm Hg). Five of ten pigs in group 1 suffered paraplegia, in contrast to none in group 2 (median Tarlov score 6, vs 9; p=0.0031). Histopathologic analysis showed more severe ischemic damage to the lower thoracic (p=0.05) and lumbar spinal cord (p=0.002) in group 1.These results underline the potential of the staged approach in hybrid procedures. Furthermore they highlight the need for established adjuncts for preventing paraplegia in hybrid and pure stent-graft protocols in which sudden occlusion of multiple SAs occurs.