When planning an EXCOR implantation, concomitant procedures should be taken into consideration such as CABG or valve surgery. The exit sites for the EXCOR cannulas can be marked on the skin for better orientation during tunneling (see ◘ Fig. 30.6). A transesophageal echocardiography is mandatory for cardiac visualization and implantation guidance.

Under general anesthesia a median sternotomy is carried out, the pericardium is widely opened, and ECC is installed in standard fashion. In a BVAD patient or if other procedures are required (e.g., TVR), bicaval venous return using single-stage CPB cannulas is advantageous. Apart from a better access to the right atrium, the PA anastomosis can be performed without clamping when running on total CPB. The cannulation of the aortic CPB cannula should be done slightly more distally in the aortic arch. This leaves enough space for the EXCOR outflow aortic cannula. An alternative cannulation of the right subclavian artery for redo surgery is recommended. It allows for immediate CPB start to maintain hemodynamic stability while cardiac structures can be safely dissected and exposed. An LV vent can be inserted via the upper right pulmonary vein to unload the LV and prevent air entrapment. CO2 insufflation to the operatic field is optional. The EXCOR BVAD implantation has typically the following steps of cannulation: (1) LV apex, (2) right atrium, (3) main pulmonary artery, and (4) ascending aorta.

For the majority of EXCOR implantations, left ventricular apical cannulation is the standard access for sufficient LV decompression. However, left atrial cannulation is necessary in certain pathologies. For example, in a hypertrophic or restrictive cardiomyopathy, the LV cavity can be too small when compared to LA size. Thus, the blood flow needed to fill the EXCOR pump would be limited. Another reason could be a large myocardial infarction prohibiting a safe anastomosis. In patients with severely diminished right ventricular function, RV apical cannulation instead of RA is a feasible modification, so-called biapical cannulation [4].

After the apex of the beating heart is luxated, the region for the ventriculotomy is located. The correct placement and alignment of the inflow cannula is a critical step in the procedure. Otherwise suction and insufficient pump flow will be encountered. The best area for the apical anastomosis is 2–4 cm apart from the LAD and 2–4 cm off-centered toward the anterior wall. Ideal position should be confirmed by TEE. After circular resection of myocardial tissue, 10–12 × pledgetted polypropylene 3–0 mattress sutures are placed around the apex whole (◘ Fig. 30.3). Reinforcement of the sutures can also be achieved by using PTFE or bovine pericardial stripes instead. The apex whole is explored and residual trabeculae excised to avoid obstruction of the inflow cannula. During insertion the beveled tip is directed toward the orifice of the atrioventricular valve for optimal drainage. The apical inflow cannula should be in parallel to the interventricular septum.

Finally the sutures are passed through the sewing ring of the apex cannula and tied which should result in secure hemostasis. The apical anastomosis site can be covered by a GORE-TEX membrane to prevent adhesions.

In case of LA approach, the cannula insertion should be done at the back wall of the LA between RUPV and RLPV. A purse-string technique plus interrupted polypropylene 4–0 reinforced sutures can be used for proper fixation. The RA cannula is inserted at the free wall between IVC and SVC and fixed with the same technique as described for LA cannulation.

The anastomosis of the outflow cannulas to ascending aorta and PA is performed after site bite clamping (or alternatively for PA without clamping when on total bypass) in end-to-side fashion (◘ Fig. 30.4). Adequate incision length is important to allow for tension-free suturing. Tear at the vascular wall can lead to bleeding complications especially at the aorta due to higher-pressure environment. Running or interrupted suture technique with polypropylene 4–0 or 5–0 can be used for cannula fixation.

Two different models of the arterial cannula with either a 85° or 60° angle of the tip are available. There is also a special graft adapter cannula which can be combined with any graft material for vascular anastomosis (◘ Fig. 30.5).

In case of a small vessel anatomy, the use of the 9 mm EXCOR standard arterial or a graft adapter cannula should be considered.

The EXCOR cannulas are tunneled subcostally through the muscle fascia and the subcutaneous tissue. This is done before preparation of the anastomosis except for the apex cannula. Proper location of the exit site for each cannula is depicted in ◘ Fig. 30.6.