The conventional surgical technique for placement of the inflow cannula requires the patient to be on cardiopulmonary bypass to provide hemodynamic stability, while the heart is decompressed to facilitate medial displacement and exposure of the apex of the left ventricle.

Position of arterial cannula and number and position of venous cannulas to establish cardiopulmonary bypass will be determined by the condition of the patient, prior cardiac surgeries, or need to perform additional procedures during the implantation of LVAD. While standard technique is done with single venous cannula, alternative bicaval cannulation will be used if patient requires simultaneous closure of a patent foramen ovale or repair of the tricuspid valve.

Intraoperative transesophageal echocardiogram provides thorough assessment of cardiac anatomy and function, and it is important to determine if patient presents cardiac pathologies that require concomitant surgical repair at time of LVAD implantation, including moderate-severe aortic insufficiency, patent foramen ovale or atrial septal defect, and tricuspid regurgitation. These pathologies are treated before the implantation of LVAD and most of the time can be surgically repaired. Occasionally, patients with severe aortic insufficiency related to a thickened and retracted leaflets will require aortic valve, and we favor implantation of bioprosthesis. While most surgeons will not perform repair for severe mitral valve insufficiency, some authors advocate plication of the central aspect of both leaflets (Alfieri stitch) from the ventricular aspect of the valve after coring the apex of the heart.

Implantation of the inflow cannula of the LVAD continues after any concomitant procedure has been performed. The initial step is the creation of a circular incision in the wall of the left ventricle. The ideal position is usually 1–2 cm anterolateral to the apical dimple, which is an easily palpable location of thinner myocardial wall. A full-thickness piece of myocardial core is removed, and the opening is inspected closely for thrombi or adjacent trabeculae, both of which are carefully removed to create an unobstructed funnel to harbor the inflow cannula (◘ Fig. 26.2). Chronic thrombus that is well embedded to the left ventricular wall and not protruding in the funnel can be left alone. For patients presenting severe mitral regurgitation, some authors favor repair of severe mitral regurgitation with an edge-edge stitch that can be placed from the ventricular core opening at this stage of the procedure.

By choosing the correct position on the LV apex, the ideal orientation of the inflow cannula pointing toward the mitral valve and parallel to the ventricular septum can be achieved. Creating adequate space for the pump pocket is important to prevent inadvertent malposition of the inflow cannula when the heart is returned to the anatomic position.

Next, 2-0 Tevdek sutures supported with 3 x 8 mm Teflon pledgets are placed in a full-thickness fashion through the myocardial core and passed through the felt portion of the sewing cuff or ring. A variety of techniques can be utilized to place this stitches so that they provide adequate support to the inflow cannula. Our preference is to place a total of twelve stitches along the circumference of the LV opening. Four initial stitches are placed in the cardinal points, while the other eight are equally distributed along the circumference with two on each quadrant. We have found that placing each stitch from outside-in about 1 cm from the edge and coming back out 3–5 mm from the edge of the core incision provides very good support and hemostasis.

Alternative techniques include the reinforcement of the sawing ring with a segment of Teflon felt patch or autologous pericardium fashioned as a donut that matches the coring incision on the wall of the left ventricle. These reinforcement strategies may be particularly useful in patients with recent myocardial infarction.

A couple of alternative techniques have been described to decrease the impact of the surgery on patients receiving LVAD, who are often times debilitated and fragile, and facilitate postoperative recovery. Minimally invasive approaches were proposed to decrease the trauma created by surgery, and techniques that avoid use of cardiopulmonary bypass machine aim to attenuate the inflammatory response of patients triggered by extracorporeal circulation.

Both approaches warrant some specific considerations related to the implantation of the inflow cannula, and more complete discussion of other technical aspects is discussed in detail in other sections of this book.

Of note, cardiopulmonary bypass can be instituted though central or peripheral cannulation, and concomitant structural heart procedures could be performed although the exposure is limited and can add complexity to the procedures [2, 3].