(a) The pump is exposed through an extended left subcostal incision . A self-retaining retractor is invaluable in visualizing the white silicone rubber bellows that surrounds the pump inlet graft. (b) The bend-relief is disconnected from the pump outlet so that the outflow graft can be exposed. After hemodynamic stability is ensured, the pump power is turned off, and the driveline is cut. (c) Clamps are immediately placed on the outlet graft and the silicone rubber inflow bellows to prevent retrograde flow through the nonfunctioning pump. (d) The outflow graft is unscrewed from the curved titanium tube at the pump outlet. Brisk backflow is confirmed by transiently releasing the clamp to ensure adequacy of the outflow graft. (e) A pump clamp is used to firmly grasp the collar at the pump inlet. (f) While the collar is held, the pump is rotated counterclockwise until it can be removed from the inlet. Brisk bleeding from the inlet is confirmed by transiently releasing the clamp on the inflow bellows to ensure adequacy of the pump inflow. The new pump is implanted by performing these steps in the reverse order