PMC:6640909 / 24315-33408 JSONTXT

{"project":"TEST0","denotations":[{"id":"31100109-224-230-7256","span":{"begin":292,"end":294},"obj":"[\"20123242\"]"},{"id":"31100109-9-16-7257","span":{"begin":296,"end":299},"obj":"[\"21545946\"]"},{"id":"31100109-14-21-7258","span":{"begin":301,"end":304},"obj":"[\"22619284\"]"},{"id":"31100109-19-26-7259","span":{"begin":306,"end":309},"obj":"[\"27959709\"]"},{"id":"31100109-24-31-7260","span":{"begin":311,"end":314},"obj":"[\"26670056\"]"},{"id":"31100109-226-233-7261","span":{"begin":484,"end":487},"obj":"[\"27658844\"]"},{"id":"31100109-228-235-7262","span":{"begin":630,"end":633},"obj":"[\"16678026\"]"},{"id":"31100109-8-15-7263","span":{"begin":635,"end":638},"obj":"[\"27751582\"]"},{"id":"31100109-237-243-7264","span":{"begin":832,"end":834},"obj":"[\"20123242\"]"},{"id":"31100109-232-239-7265","span":{"begin":1017,"end":1020},"obj":"[\"26670056\"]"},{"id":"31100109-236-242-7266","span":{"begin":1160,"end":1162},"obj":"[\"20123242\"]"},{"id":"31100109-231-238-7267","span":{"begin":1164,"end":1167},"obj":"[\"21545946\"]"},{"id":"31100109-228-234-7268","span":{"begin":1275,"end":1277},"obj":"[\"20123242\"]"},{"id":"31100109-236-242-7269","span":{"begin":1358,"end":1360},"obj":"[\"20123242\"]"},{"id":"31100109-235-241-7270","span":{"begin":1549,"end":1551},"obj":"[\"20123242\"]"},{"id":"31100109-232-238-7271","span":{"begin":1721,"end":1723},"obj":"[\"20123242\"]"},{"id":"31100109-236-243-7272","span":{"begin":1725,"end":1728},"obj":"[\"27087560\"]"},{"id":"31100109-227-234-7273","span":{"begin":1882,"end":1885},"obj":"[\"27087560\"]"},{"id":"31100109-10-17-7274","span":{"begin":1887,"end":1890},"obj":"[\"25981314\"]"},{"id":"31100109-236-242-7275","span":{"begin":2070,"end":2072},"obj":"[\"20123242\"]"},{"id":"31100109-232-239-7276","span":{"begin":2074,"end":2077},"obj":"[\"27087560\"]"},{"id":"31100109-232-239-7277","span":{"begin":2292,"end":2295},"obj":"[\"27087560\"]"},{"id":"31100109-232-239-7278","span":{"begin":2433,"end":2436},"obj":"[\"27087560\"]"},{"id":"31100109-227-234-7279","span":{"begin":2601,"end":2604},"obj":"[\"23438784\"]"},{"id":"31100109-10-17-7280","span":{"begin":2606,"end":2609},"obj":"[\"23438769\"]"},{"id":"31100109-231-237-7281","span":{"begin":2992,"end":2994},"obj":"[\"20123242\"]"},{"id":"31100109-235-242-7282","span":{"begin":2996,"end":2999},"obj":"[\"26670056\"]"},{"id":"31100109-237-243-7283","span":{"begin":3154,"end":3156},"obj":"[\"20123242\"]"},{"id":"31100109-9-16-7284","span":{"begin":3158,"end":3161},"obj":"[\"26670056\"]"},{"id":"31100109-237-243-7285","span":{"begin":3274,"end":3276},"obj":"[\"20123242\"]"},{"id":"31100109-234-240-7286","span":{"begin":3376,"end":3378},"obj":"[\"20123242\"]"},{"id":"31100109-231-238-7287","span":{"begin":3726,"end":3729},"obj":"[\"28962493\"]"},{"id":"31100109-222-228-7288","span":{"begin":3959,"end":3961},"obj":"[\"20123242\"]"},{"id":"31100109-226-233-7289","span":{"begin":3963,"end":3966},"obj":"[\"26670056\"]"},{"id":"31100109-9-16-7290","span":{"begin":4127,"end":4130},"obj":"[\"27347709\"]"},{"id":"31100109-14-21-7291","span":{"begin":4132,"end":4135},"obj":"[\"21049276\"]"},{"id":"31100109-19-26-7292","span":{"begin":4137,"end":4140},"obj":"[\"25452914\"]"},{"id":"31100109-234-241-7293","span":{"begin":4544,"end":4547},"obj":"[\"24623170\"]"},{"id":"31100109-10-17-7294","span":{"begin":4549,"end":4552},"obj":"[\"25659850\"]"},{"id":"31100109-226-233-7295","span":{"begin":4753,"end":4756},"obj":"[\"25735901\"]"},{"id":"31100109-228-235-7296","span":{"begin":4889,"end":4892},"obj":"[\"21987183\"]"},{"id":"31100109-229-236-7297","span":{"begin":5002,"end":5005},"obj":"[\"25735901\"]"},{"id":"31100109-8-15-7298","span":{"begin":5007,"end":5010},"obj":"[\"21987183\"]"},{"id":"31100109-230-237-7299","span":{"begin":5114,"end":5117},"obj":"[\"14981007\"]"},{"id":"31100109-8-15-7300","span":{"begin":5119,"end":5122},"obj":"[\"11789775\"]"},{"id":"31100109-230-236-7301","span":{"begin":5227,"end":5229},"obj":"[\"20123242\"]"},{"id":"31100109-232-238-7302","span":{"begin":5316,"end":5318},"obj":"[\"20123242\"]"},{"id":"31100109-224-231-7303","span":{"begin":5566,"end":5569},"obj":"[\"24571624\"]"},{"id":"31100109-10-17-7304","span":{"begin":5898,"end":5901},"obj":"[\"27347709\"]"},{"id":"31100109-15-22-7305","span":{"begin":5903,"end":5906},"obj":"[\"25063531\"]"},{"id":"31100109-10-17-7306","span":{"begin":6004,"end":6007},"obj":"[\"24623170\"]"},{"id":"31100109-225-231-7307","span":{"begin":6631,"end":6633},"obj":"[\"20123242\"]"},{"id":"31100109-236-243-7308","span":{"begin":6749,"end":6752},"obj":"[\"22975102\"]"},{"id":"31100109-234-241-7309","span":{"begin":7377,"end":7380},"obj":"[\"29861112\"]"},{"id":"31100109-233-240-7310","span":{"begin":7535,"end":7538},"obj":"[\"29861112\"]"},{"id":"31100109-10-17-7311","span":{"begin":7540,"end":7543},"obj":"[\"27569985\"]"},{"id":"31100109-236-243-7312","span":{"begin":7688,"end":7691},"obj":"[\"27569985\"]"},{"id":"31100109-10-17-7313","span":{"begin":7693,"end":7696},"obj":"[\"20705484\"]"},{"id":"31100109-235-242-7314","span":{"begin":7833,"end":7836},"obj":"[\"29294144\"]"},{"id":"31100109-234-241-7315","span":{"begin":7955,"end":7958},"obj":"[\"28734448\"]"},{"id":"31100109-232-239-7316","span":{"begin":8123,"end":8126},"obj":"[\"29157741\"]"},{"id":"31100109-8-15-7317","span":{"begin":8128,"end":8131},"obj":"[\"22243702\"]"},{"id":"31100109-13-20-7318","span":{"begin":8133,"end":8136},"obj":"[\"21911810\"]"},{"id":"31100109-18-25-7319","span":{"begin":8138,"end":8141},"obj":"[\"21851956\"]"},{"id":"31100109-23-30-7320","span":{"begin":8143,"end":8146},"obj":"[\"21490553\"]"},{"id":"31100109-28-35-7321","span":{"begin":8148,"end":8151},"obj":"[\"23438782\"]"},{"id":"31100109-229-236-7322","span":{"begin":8363,"end":8366},"obj":"[\"18242292\"]"},{"id":"31100109-223-230-7323","span":{"begin":8603,"end":8606},"obj":"[\"24571624\"]"},{"id":"31100109-235-242-7324","span":{"begin":8822,"end":8825},"obj":"[\"20705484\"]"},{"id":"31100109-10-17-7325","span":{"begin":8827,"end":8830},"obj":"[\"18022090\"]"},{"id":"31100109-210-217-7326","span":{"begin":9034,"end":9037},"obj":"[\"25843517\"]"},{"id":"31100109-215-222-7327","span":{"begin":9039,"end":9042},"obj":"[\"28885377\"]"}],"text":"Recommendations for operative technique\nRecommendations Class Level References\nUse of circulatory assistance during implantation: implant strategy\nThe use of cardiopulmonary bypass during implantation of a long-term mechanical circulatory support device should be considered. IIa C [37, 138, 141, 145, 247]\nIn case of no necessary concomitant intracardiac procedure, implantation of LT-MCS on extracorporeal life support or off-pump implantation may be considered. IIb C [248]\nIn off-pump mechanical circulatory support implantation, secured vascular access for bail-out cardiopulmonary bypass is recommended. I C [249, 250]\nMechanical circulatory support site preparation\nFor non-intrapericardial devices, creation of the pump pocket by left hemidiaphragm transection to accommodate the pump is recommended. I C [37]\nFor intrapericardial devices, in case of pericardial pouch-device mismatch, incising the pericardium to allow pump placement in the left pleural cavity may be considered. IIb C [247]\nImplantable left vascular assist device—inflow cannula placement\nInflow cannula placement into the left ventricle is recommended. I A [37, 138]\nThe use of transoesophageal echocardiography to check the inflow cannula position is recommended. I C [37]\nPlacement of the inflow cannula parallel to the septum is recommended. I B [37]\nInflow cannula placement in the inferior left ventricular wall may be considered. IIb C\nInflow cannula placement in the lateral left ventricular free wall is not recommended. III C [37]\nApical cuff positioning\nApical cuff affixing with the sew first and then core technique, without other intraventricular manipulation necessary, is recommended. I C [37, 251]\nApical cuff affixing with the sew first and then core technique with interrupted pledgeted sutures or continuous suture should be considered. IIa C [251, 252]\nApical cuff affixing with the core first and then sew technique is recommended if intraventricular procedures, e.g. thrombus removal, mitral valve repair, are necessary. I C [37, 251]\nIn the setting of acute left ventricular myocardial infarction due to friable tissue, the sew first and then core technique with use of circular reinforcement strips and surgical glue may be considered. IIb C [251]\nApical cuff affixing with the core first and then sew technique with interrupted pledgeted reverse sutures may be considered. IIb C [251]\nIn the setting of hypertrophic or non-compaction cardiomyopathies, a partial intracavitary excision prior to the apical cuff affixing may be considered. IIb C [253, 254]\nIn the setting of acute left ventricular myocardial infarction with friable tissue of the apex, the use of temporary mechanical circulatory support may be considered to defer a long-term mechanical circulatory support implant. IIb C\nImplantable left ventricular assist device: outflow graft\nPerforming the outflow graft anastomosis on the ascending aorta is recommended. I C [37, 247]\nPerforming the outflow graft-ascending aortic anastomosis at a 45° angle should be considered to reduce the risk of late aortic insufficiency. IIa C [37, 247]\nThe use of surgical glue to secure the haemostasis of the graft-aorta anastomosis may be considered. IIb C [37]\nUsing the longitudinal line marker on the outflow graft to avoid twisting is recommended. I C [37]\nPositioning the outflow graft along the inferior right ventricular surface and between the right atrium and pericardium to avoid crossing the right ventricular outflow tract should be considered. IIa C\nPositioning the outflow graft through the transverse sinus onto the posterolateral aspect of the ascending aorta may be considered. IIb C [255]\nImplantable left ventricular assist device: alternative implant strategy/left thoracotomy approach\nAn intrapericardial course of the outflow graft in patients without previous cardiac surgical procedures is recommended. I C [37, 247]\nThe outflow graft anastomosis to the descending aorta may be considered in redo patients and patients with a severely calcified ascending aorta. IIb C [152–154, 256, 257]\nA left pleural cavity course of the outflow graft in redo implants with the anastomosis on the ascending aorta may be considered. IIb C\nIn redo implants or for patients in whom an aortic anastomosis is not amenable, anastomosis of the outflow graft to the axillary artery may be considered. In this scenario, distal banding of the axillary artery to avoid hyperperfusion may be considered. IIb C [153, 258]\nDriveline externalization\nThe course of the driveline with an intermediate incision (C-shape) to maximize the pump-to-exit site distance and to alleviate traction forces may be considered. IIb C [259]\nA partial course of the driveline through the rectus abdominis muscle to enhance the barrier for infection is recommended. I C [260]\nIt is recommended that the portion of the driveline covered in velour is completely intracorporeal. I C [259, 260]\nAir embolism prevention\nCarbon dioxide insufflation within the surgical field is recommended. I B [261, 262]\nHaving the patient in the Trendelenburg position at the time of de-airing may be considered. IIb C [37]\nLiberal de-airing via the outflow graft is recommended with on-pump surgery. I C [37]\nOversewing or glue application on the outflow graft de-airing spot to obviate late bleeding in patients having anticoagulation therapy may be considered. IIb C\nCareful de-airing strategy in off-pump implantation should be considered. IIa C [263]\nActive suction (needle venting) may be considered. IIb C\nAlternative implant surgical strategy\nLeft anterior thoracotomy at a level of the apex validated by echocardiography or computed tomography is recommended. I C [151–154]\nA partial upper sternotomy for the outflow graft anastomosis may be considered. IIb C [151, 152, 154]\nA right lateral thoracotomy for the outflow graft anastomosis may be considered. IIb C [151, 153]\nAn alternative implant strategy with the outflow graft tunnelled via pleural cavities in redo implants without the need for major concomitant procedures may be considered. IIb C\nIn patients with a history of cardiac surgery through a median sternotomy and who do not require concomitant cardiac surgery other than implantation of long-term mechanical circulatory support, implantation through a left lateral thoracotomy with connection of the outflow graft to the descending aorta may be considered. IIb C\nClosing surgical operation field considerations\nLiberal use of chest and pleural drains is recommended. I C [37]\nIn the case of major coagulopathy, a provisional chest closure with surgical packing may be considered. IIb C [264]\nIn patients with the prospect of a heart transplant, strategies to limit adhesions during implantation should be considered. IIa C\nBiventricular support\nUse of temporary short-term right heart support to allow for a subsequent explant without sternal reopening should be considered. Various possibilities can be considered: cannulation of the right atrium via the femoral vein for blood inflow and for blood return cannulation of vascular graft attached to the pulmonary artery or cannulation through the jugular vein. An additional option may be an endovascular microaxial pump inserted into pulmonary artery. IIa C [265]\nFor implantable right ventricular assist device support, insertion of the inflow cannula insertion into the right atrium should be considered. IIa C [265, 266]\nFor implantable right ventricular assist device support, insertion of the inflow cannula into the right ventricle may be considered. IIb C [266, 267]\nLong-term paracorporeal support\nApical cannulation of the left ventricle should be considered for the left side of the pump. IIa C [188]\nIn patients with restrictive/obstructive cardiomyopathy, cannulation in the left atrium may be considered. IIb C [268]\nTotal artificial heart\nAn atrial connection at the level of the atrioventricular valves and outflow grafts connected to the great vessels are recommended. I C [192, 193, 196, 206, 269, 270]\nLong-term mechanical circulatory support explant\nComplete circulatory support system explant is recommended in cases of active device infection or in patients at a high risk of infective complications. I C [271]\nAfter mechanical circulatory support explant for infection, stabilization with temporary mechanical circulatory support in conjunction with comprehensive antimicrobial therapy may be considered as a bridge to reimplantation. IIb C [263]\nAfter myocardial recovery without signs of infection, removal of the pump with a dedicated titanium sintered plug, outflow graft ligation and removal of the driveline should be considered where possible. IIa C [267, 272]\nAfter heart recovery without signs of infection, decommissioning with outflow graft ligation or endovascular occlusion with partial removal/internalization of the driveline may be considered. IIa C [273, 274]\nLT-MCS: long-term mechanical circulatory support."}

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for operative technique\nRecommendations Class Level References\nUse of circulatory assistance during implantation: implant strategy\nThe use of cardiopulmonary bypass during implantation of a long-term mechanical circulatory support device should be considered. IIa C [37, 138, 141, 145, 247]\nIn case of no necessary concomitant intracardiac procedure, implantation of LT-MCS on extracorporeal life support or off-pump implantation may be considered. IIb C [248]\nIn off-pump mechanical circulatory support implantation, secured vascular access for bail-out cardiopulmonary bypass is recommended. I C [249, 250]\nMechanical circulatory support site preparation\nFor non-intrapericardial devices, creation of the pump pocket by left hemidiaphragm transection to accommodate the pump is recommended. I C [37]\nFor intrapericardial devices, in case of pericardial pouch-device mismatch, incising the pericardium to allow pump placement in the left pleural cavity may be considered. IIb C [247]\nImplantable left vascular assist device—inflow cannula placement\nInflow cannula placement into the left ventricle is recommended. I A [37, 138]\nThe use of transoesophageal echocardiography to check the inflow cannula position is recommended. I C [37]\nPlacement of the inflow cannula parallel to the septum is recommended. I B [37]\nInflow cannula placement in the inferior left ventricular wall may be considered. IIb C\nInflow cannula placement in the lateral left ventricular free wall is not recommended. III C [37]\nApical cuff positioning\nApical cuff affixing with the sew first and then core technique, without other intraventricular manipulation necessary, is recommended. I C [37, 251]\nApical cuff affixing with the sew first and then core technique with interrupted pledgeted sutures or continuous suture should be considered. IIa C [251, 252]\nApical cuff affixing with the core first and then sew technique is recommended if intraventricular procedures, e.g. thrombus removal, mitral valve repair, are necessary. I C [37, 251]\nIn the setting of acute left ventricular myocardial infarction due to friable tissue, the sew first and then core technique with use of circular reinforcement strips and surgical glue may be considered. IIb C [251]\nApical cuff affixing with the core first and then sew technique with interrupted pledgeted reverse sutures may be considered. IIb C [251]\nIn the setting of hypertrophic or non-compaction cardiomyopathies, a partial intracavitary excision prior to the apical cuff affixing may be considered. IIb C [253, 254]\nIn the setting of acute left ventricular myocardial infarction with friable tissue of the apex, the use of temporary mechanical circulatory support may be considered to defer a long-term mechanical circulatory support implant. IIb C\nImplantable left ventricular assist device: outflow graft\nPerforming the outflow graft anastomosis on the ascending aorta is recommended. I C [37, 247]\nPerforming the outflow graft-ascending aortic anastomosis at a 45° angle should be considered to reduce the risk of late aortic insufficiency. IIa C [37, 247]\nThe use of surgical glue to secure the haemostasis of the graft-aorta anastomosis may be considered. IIb C [37]\nUsing the longitudinal line marker on the outflow graft to avoid twisting is recommended. I C [37]\nPositioning the outflow graft along the inferior right ventricular surface and between the right atrium and pericardium to avoid crossing the right ventricular outflow tract should be considered. IIa C\nPositioning the outflow graft through the transverse sinus onto the posterolateral aspect of the ascending aorta may be considered. IIb C [255]\nImplantable left ventricular assist device: alternative implant strategy/left thoracotomy approach\nAn intrapericardial course of the outflow graft in patients without previous cardiac surgical procedures is recommended. I C [37, 247]\nThe outflow graft anastomosis to the descending aorta may be considered in redo patients and patients with a severely calcified ascending aorta. IIb C [152–154, 256, 257]\nA left pleural cavity course of the outflow graft in redo implants with the anastomosis on the ascending aorta may be considered. IIb C\nIn redo implants or for patients in whom an aortic anastomosis is not amenable, anastomosis of the outflow graft to the axillary artery may be considered. In this scenario, distal banding of the axillary artery to avoid hyperperfusion may be considered. IIb C [153, 258]\nDriveline externalization\nThe course of the driveline with an intermediate incision (C-shape) to maximize the pump-to-exit site distance and to alleviate traction forces may be considered. IIb C [259]\nA partial course of the driveline through the rectus abdominis muscle to enhance the barrier for infection is recommended. I C [260]\nIt is recommended that the portion of the driveline covered in velour is completely intracorporeal. I C [259, 260]\nAir embolism prevention\nCarbon dioxide insufflation within the surgical field is recommended. I B [261, 262]\nHaving the patient in the Trendelenburg position at the time of de-airing may be considered. IIb C [37]\nLiberal de-airing via the outflow graft is recommended with on-pump surgery. I C [37]\nOversewing or glue application on the outflow graft de-airing spot to obviate late bleeding in patients having anticoagulation therapy may be considered. IIb C\nCareful de-airing strategy in off-pump implantation should be considered. IIa C [263]\nActive suction (needle venting) may be considered. IIb C\nAlternative implant surgical strategy\nLeft anterior thoracotomy at a level of the apex validated by echocardiography or computed tomography is recommended. I C [151–154]\nA partial upper sternotomy for the outflow graft anastomosis may be considered. IIb C [151, 152, 154]\nA right lateral thoracotomy for the outflow graft anastomosis may be considered. IIb C [151, 153]\nAn alternative implant strategy with the outflow graft tunnelled via pleural cavities in redo implants without the need for major concomitant procedures may be considered. IIb C\nIn patients with a history of cardiac surgery through a median sternotomy and who do not require concomitant cardiac surgery other than implantation of long-term mechanical circulatory support, implantation through a left lateral thoracotomy with connection of the outflow graft to the descending aorta may be considered. IIb C\nClosing surgical operation field considerations\nLiberal use of chest and pleural drains is recommended. I C [37]\nIn the case of major coagulopathy, a provisional chest closure with surgical packing may be considered. IIb C [264]\nIn patients with the prospect of a heart transplant, strategies to limit adhesions during implantation should be considered. IIa C\nBiventricular support\nUse of temporary short-term right heart support to allow for a subsequent explant without sternal reopening should be considered. Various possibilities can be considered: cannulation of the right atrium via the femoral vein for blood inflow and for blood return cannulation of vascular graft attached to the pulmonary artery or cannulation through the jugular vein. An additional option may be an endovascular microaxial pump inserted into pulmonary artery. IIa C [265]\nFor implantable right ventricular assist device support, insertion of the inflow cannula insertion into the right atrium should be considered. IIa C [265, 266]\nFor implantable right ventricular assist device support, insertion of the inflow cannula into the right ventricle may be considered. IIb C [266, 267]\nLong-term paracorporeal support\nApical cannulation of the left ventricle should be considered for the left side of the pump. IIa C [188]\nIn patients with restrictive/obstructive cardiomyopathy, cannulation in the left atrium may be considered. IIb C [268]\nTotal artificial heart\nAn atrial connection at the level of the atrioventricular valves and outflow grafts connected to the great vessels are recommended. I C [192, 193, 196, 206, 269, 270]\nLong-term mechanical circulatory support explant\nComplete circulatory support system explant is recommended in cases of active device infection or in patients at a high risk of infective complications. I C [271]\nAfter mechanical circulatory support explant for infection, stabilization with temporary mechanical circulatory support in conjunction with comprehensive antimicrobial therapy may be considered as a bridge to reimplantation. IIb C [263]\nAfter myocardial recovery without signs of infection, removal of the pump with a dedicated titanium sintered plug, outflow graft ligation and removal of the driveline should be considered where possible. IIa C [267, 272]\nAfter heart recovery without signs of infection, decommissioning with outflow graft ligation or endovascular occlusion with partial removal/internalization of the driveline may be considered. IIa C [273, 274]\nLT-MCS: long-term mechanical circulatory support."}

{"project":"0_colil","denotations":[{"id":"31100109-20123242-7256","span":{"begin":292,"end":294},"obj":"20123242"},{"id":"31100109-21545946-7257","span":{"begin":296,"end":299},"obj":"21545946"},{"id":"31100109-22619284-7258","span":{"begin":301,"end":304},"obj":"22619284"},{"id":"31100109-27959709-7259","span":{"begin":306,"end":309},"obj":"27959709"},{"id":"31100109-26670056-7260","span":{"begin":311,"end":314},"obj":"26670056"},{"id":"31100109-27658844-7261","span":{"begin":484,"end":487},"obj":"27658844"},{"id":"31100109-16678026-7262","span":{"begin":630,"end":633},"obj":"16678026"},{"id":"31100109-27751582-7263","span":{"begin":635,"end":638},"obj":"27751582"},{"id":"31100109-20123242-7264","span":{"begin":832,"end":834},"obj":"20123242"},{"id":"31100109-26670056-7265","span":{"begin":1017,"end":1020},"obj":"26670056"},{"id":"31100109-20123242-7266","span":{"begin":1160,"end":1162},"obj":"20123242"},{"id":"31100109-21545946-7267","span":{"begin":1164,"end":1167},"obj":"21545946"},{"id":"31100109-20123242-7268","span":{"begin":1275,"end":1277},"obj":"20123242"},{"id":"31100109-20123242-7269","span":{"begin":1358,"end":1360},"obj":"20123242"},{"id":"31100109-20123242-7270","span":{"begin":1549,"end":1551},"obj":"20123242"},{"id":"31100109-20123242-7271","span":{"begin":1721,"end":1723},"obj":"20123242"},{"id":"31100109-27087560-7272","span":{"begin":1725,"end":1728},"obj":"27087560"},{"id":"31100109-27087560-7273","span":{"begin":1882,"end":1885},"obj":"27087560"},{"id":"31100109-25981314-7274","span":{"begin":1887,"end":1890},"obj":"25981314"},{"id":"31100109-20123242-7275","span":{"begin":2070,"end":2072},"obj":"20123242"},{"id":"31100109-27087560-7276","span":{"begin":2074,"end":2077},"obj":"27087560"},{"id":"31100109-27087560-7277","span":{"begin":2292,"end":2295},"obj":"27087560"},{"id":"31100109-27087560-7278","span":{"begin":2433,"end":2436},"obj":"27087560"},{"id":"31100109-23438784-7279","span":{"begin":2601,"end":2604},"obj":"23438784"},{"id":"31100109-23438769-7280","span":{"begin":2606,"end":2609},"obj":"23438769"},{"id":"31100109-20123242-7281","span":{"begin":2992,"end":2994},"obj":"20123242"},{"id":"31100109-26670056-7282","span":{"begin":2996,"end":2999},"obj":"26670056"},{"id":"31100109-20123242-7283","span":{"begin":3154,"end":3156},"obj":"20123242"},{"id":"31100109-26670056-7284","span":{"begin":3158,"end":3161},"obj":"26670056"},{"id":"31100109-20123242-7285","span":{"begin":3274,"end":3276},"obj":"20123242"},{"id":"31100109-20123242-7286","span":{"begin":3376,"end":3378},"obj":"20123242"},{"id":"31100109-28962493-7287","span":{"begin":3726,"end":3729},"obj":"28962493"},{"id":"31100109-20123242-7288","span":{"begin":3959,"end":3961},"obj":"20123242"},{"id":"31100109-26670056-7289","span":{"begin":3963,"end":3966},"obj":"26670056"},{"id":"31100109-27347709-7290","span":{"begin":4127,"end":4130},"obj":"27347709"},{"id":"31100109-21049276-7291","span":{"begin":4132,"end":4135},"obj":"21049276"},{"id":"31100109-25452914-7292","span":{"begin":4137,"end":4140},"obj":"25452914"},{"id":"31100109-24623170-7293","span":{"begin":4544,"end":4547},"obj":"24623170"},{"id":"31100109-25659850-7294","span":{"begin":4549,"end":4552},"obj":"25659850"},{"id":"31100109-25735901-7295","span":{"begin":4753,"end":4756},"obj":"25735901"},{"id":"31100109-21987183-7296","span":{"begin":4889,"end":4892},"obj":"21987183"},{"id":"31100109-25735901-7297","span":{"begin":5002,"end":5005},"obj":"25735901"},{"id":"31100109-21987183-7298","span":{"begin":5007,"end":5010},"obj":"21987183"},{"id":"31100109-14981007-7299","span":{"begin":5114,"end":5117},"obj":"14981007"},{"id":"31100109-11789775-7300","span":{"begin":5119,"end":5122},"obj":"11789775"},{"id":"31100109-20123242-7301","span":{"begin":5227,"end":5229},"obj":"20123242"},{"id":"31100109-20123242-7302","span":{"begin":5316,"end":5318},"obj":"20123242"},{"id":"31100109-24571624-7303","span":{"begin":5566,"end":5569},"obj":"24571624"},{"id":"31100109-27347709-7304","span":{"begin":5898,"end":5901},"obj":"27347709"},{"id":"31100109-25063531-7305","span":{"begin":5903,"end":5906},"obj":"25063531"},{"id":"31100109-24623170-7306","span":{"begin":6004,"end":6007},"obj":"24623170"},{"id":"31100109-20123242-7307","span":{"begin":6631,"end":6633},"obj":"20123242"},{"id":"31100109-22975102-7308","span":{"begin":6749,"end":6752},"obj":"22975102"},{"id":"31100109-29861112-7309","span":{"begin":7377,"end":7380},"obj":"29861112"},{"id":"31100109-29861112-7310","span":{"begin":7535,"end":7538},"obj":"29861112"},{"id":"31100109-27569985-7311","span":{"begin":7540,"end":7543},"obj":"27569985"},{"id":"31100109-27569985-7312","span":{"begin":7688,"end":7691},"obj":"27569985"},{"id":"31100109-20705484-7313","span":{"begin":7693,"end":7696},"obj":"20705484"},{"id":"31100109-29294144-7314","span":{"begin":7833,"end":7836},"obj":"29294144"},{"id":"31100109-28734448-7315","span":{"begin":7955,"end":7958},"obj":"28734448"},{"id":"31100109-29157741-7316","span":{"begin":8123,"end":8126},"obj":"29157741"},{"id":"31100109-22243702-7317","span":{"begin":8128,"end":8131},"obj":"22243702"},{"id":"31100109-21911810-7318","span":{"begin":8133,"end":8136},"obj":"21911810"},{"id":"31100109-21851956-7319","span":{"begin":8138,"end":8141},"obj":"21851956"},{"id":"31100109-21490553-7320","span":{"begin":8143,"end":8146},"obj":"21490553"},{"id":"31100109-23438782-7321","span":{"begin":8148,"end":8151},"obj":"23438782"},{"id":"31100109-18242292-7322","span":{"begin":8363,"end":8366},"obj":"18242292"},{"id":"31100109-24571624-7323","span":{"begin":8603,"end":8606},"obj":"24571624"},{"id":"31100109-20705484-7324","span":{"begin":8822,"end":8825},"obj":"20705484"},{"id":"31100109-18022090-7325","span":{"begin":8827,"end":8830},"obj":"18022090"},{"id":"31100109-25843517-7326","span":{"begin":9034,"end":9037},"obj":"25843517"},{"id":"31100109-28885377-7327","span":{"begin":9039,"end":9042},"obj":"28885377"}],"text":"Recommendations for operative technique\nRecommendations Class Level References\nUse of circulatory assistance during implantation: implant strategy\nThe use of cardiopulmonary bypass during implantation of a long-term mechanical circulatory support device should be considered. IIa C [37, 138, 141, 145, 247]\nIn case of no necessary concomitant intracardiac procedure, implantation of LT-MCS on extracorporeal life support or off-pump implantation may be considered. IIb C [248]\nIn off-pump mechanical circulatory support implantation, secured vascular access for bail-out cardiopulmonary bypass is recommended. I C [249, 250]\nMechanical circulatory support site preparation\nFor non-intrapericardial devices, creation of the pump pocket by left hemidiaphragm transection to accommodate the pump is recommended. I C [37]\nFor intrapericardial devices, in case of pericardial pouch-device mismatch, incising the pericardium to allow pump placement in the left pleural cavity may be considered. IIb C [247]\nImplantable left vascular assist device—inflow cannula placement\nInflow cannula placement into the left ventricle is recommended. I A [37, 138]\nThe use of transoesophageal echocardiography to check the inflow cannula position is recommended. I C [37]\nPlacement of the inflow cannula parallel to the septum is recommended. I B [37]\nInflow cannula placement in the inferior left ventricular wall may be considered. IIb C\nInflow cannula placement in the lateral left ventricular free wall is not recommended. III C [37]\nApical cuff positioning\nApical cuff affixing with the sew first and then core technique, without other intraventricular manipulation necessary, is recommended. I C [37, 251]\nApical cuff affixing with the sew first and then core technique with interrupted pledgeted sutures or continuous suture should be considered. IIa C [251, 252]\nApical cuff affixing with the core first and then sew technique is recommended if intraventricular procedures, e.g. thrombus removal, mitral valve repair, are necessary. I C [37, 251]\nIn the setting of acute left ventricular myocardial infarction due to friable tissue, the sew first and then core technique with use of circular reinforcement strips and surgical glue may be considered. IIb C [251]\nApical cuff affixing with the core first and then sew technique with interrupted pledgeted reverse sutures may be considered. IIb C [251]\nIn the setting of hypertrophic or non-compaction cardiomyopathies, a partial intracavitary excision prior to the apical cuff affixing may be considered. IIb C [253, 254]\nIn the setting of acute left ventricular myocardial infarction with friable tissue of the apex, the use of temporary mechanical circulatory support may be considered to defer a long-term mechanical circulatory support implant. IIb C\nImplantable left ventricular assist device: outflow graft\nPerforming the outflow graft anastomosis on the ascending aorta is recommended. I C [37, 247]\nPerforming the outflow graft-ascending aortic anastomosis at a 45° angle should be considered to reduce the risk of late aortic insufficiency. IIa C [37, 247]\nThe use of surgical glue to secure the haemostasis of the graft-aorta anastomosis may be considered. IIb C [37]\nUsing the longitudinal line marker on the outflow graft to avoid twisting is recommended. I C [37]\nPositioning the outflow graft along the inferior right ventricular surface and between the right atrium and pericardium to avoid crossing the right ventricular outflow tract should be considered. IIa C\nPositioning the outflow graft through the transverse sinus onto the posterolateral aspect of the ascending aorta may be considered. IIb C [255]\nImplantable left ventricular assist device: alternative implant strategy/left thoracotomy approach\nAn intrapericardial course of the outflow graft in patients without previous cardiac surgical procedures is recommended. I C [37, 247]\nThe outflow graft anastomosis to the descending aorta may be considered in redo patients and patients with a severely calcified ascending aorta. IIb C [152–154, 256, 257]\nA left pleural cavity course of the outflow graft in redo implants with the anastomosis on the ascending aorta may be considered. IIb C\nIn redo implants or for patients in whom an aortic anastomosis is not amenable, anastomosis of the outflow graft to the axillary artery may be considered. In this scenario, distal banding of the axillary artery to avoid hyperperfusion may be considered. IIb C [153, 258]\nDriveline externalization\nThe course of the driveline with an intermediate incision (C-shape) to maximize the pump-to-exit site distance and to alleviate traction forces may be considered. IIb C [259]\nA partial course of the driveline through the rectus abdominis muscle to enhance the barrier for infection is recommended. I C [260]\nIt is recommended that the portion of the driveline covered in velour is completely intracorporeal. I C [259, 260]\nAir embolism prevention\nCarbon dioxide insufflation within the surgical field is recommended. I B [261, 262]\nHaving the patient in the Trendelenburg position at the time of de-airing may be considered. IIb C [37]\nLiberal de-airing via the outflow graft is recommended with on-pump surgery. I C [37]\nOversewing or glue application on the outflow graft de-airing spot to obviate late bleeding in patients having anticoagulation therapy may be considered. IIb C\nCareful de-airing strategy in off-pump implantation should be considered. IIa C [263]\nActive suction (needle venting) may be considered. IIb C\nAlternative implant surgical strategy\nLeft anterior thoracotomy at a level of the apex validated by echocardiography or computed tomography is recommended. I C [151–154]\nA partial upper sternotomy for the outflow graft anastomosis may be considered. IIb C [151, 152, 154]\nA right lateral thoracotomy for the outflow graft anastomosis may be considered. IIb C [151, 153]\nAn alternative implant strategy with the outflow graft tunnelled via pleural cavities in redo implants without the need for major concomitant procedures may be considered. IIb C\nIn patients with a history of cardiac surgery through a median sternotomy and who do not require concomitant cardiac surgery other than implantation of long-term mechanical circulatory support, implantation through a left lateral thoracotomy with connection of the outflow graft to the descending aorta may be considered. IIb C\nClosing surgical operation field considerations\nLiberal use of chest and pleural drains is recommended. I C [37]\nIn the case of major coagulopathy, a provisional chest closure with surgical packing may be considered. IIb C [264]\nIn patients with the prospect of a heart transplant, strategies to limit adhesions during implantation should be considered. IIa C\nBiventricular support\nUse of temporary short-term right heart support to allow for a subsequent explant without sternal reopening should be considered. Various possibilities can be considered: cannulation of the right atrium via the femoral vein for blood inflow and for blood return cannulation of vascular graft attached to the pulmonary artery or cannulation through the jugular vein. An additional option may be an endovascular microaxial pump inserted into pulmonary artery. IIa C [265]\nFor implantable right ventricular assist device support, insertion of the inflow cannula insertion into the right atrium should be considered. IIa C [265, 266]\nFor implantable right ventricular assist device support, insertion of the inflow cannula into the right ventricle may be considered. IIb C [266, 267]\nLong-term paracorporeal support\nApical cannulation of the left ventricle should be considered for the left side of the pump. IIa C [188]\nIn patients with restrictive/obstructive cardiomyopathy, cannulation in the left atrium may be considered. IIb C [268]\nTotal artificial heart\nAn atrial connection at the level of the atrioventricular valves and outflow grafts connected to the great vessels are recommended. I C [192, 193, 196, 206, 269, 270]\nLong-term mechanical circulatory support explant\nComplete circulatory support system explant is recommended in cases of active device infection or in patients at a high risk of infective complications. I C [271]\nAfter mechanical circulatory support explant for infection, stabilization with temporary mechanical circulatory support in conjunction with comprehensive antimicrobial therapy may be considered as a bridge to reimplantation. IIb C [263]\nAfter myocardial recovery without signs of infection, removal of the pump with a dedicated titanium sintered plug, outflow graft ligation and removal of the driveline should be considered where possible. IIa C [267, 272]\nAfter heart recovery without signs of infection, decommissioning with outflow graft ligation or endovascular occlusion with partial removal/internalization of the driveline may be considered. IIa C [273, 274]\nLT-MCS: long-term mechanical circulatory support."}

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for operative technique\nRecommendations Class Level References\nUse of circulatory assistance during implantation: implant strategy\nThe use of cardiopulmonary bypass during implantation of a long-term mechanical circulatory support device should be considered. IIa C [37, 138, 141, 145, 247]\nIn case of no necessary concomitant intracardiac procedure, implantation of LT-MCS on extracorporeal life support or off-pump implantation may be considered. IIb C [248]\nIn off-pump mechanical circulatory support implantation, secured vascular access for bail-out cardiopulmonary bypass is recommended. I C [249, 250]\nMechanical circulatory support site preparation\nFor non-intrapericardial devices, creation of the pump pocket by left hemidiaphragm transection to accommodate the pump is recommended. I C [37]\nFor intrapericardial devices, in case of pericardial pouch-device mismatch, incising the pericardium to allow pump placement in the left pleural cavity may be considered. IIb C [247]\nImplantable left vascular assist device—inflow cannula placement\nInflow cannula placement into the left ventricle is recommended. I A [37, 138]\nThe use of transoesophageal echocardiography to check the inflow cannula position is recommended. I C [37]\nPlacement of the inflow cannula parallel to the septum is recommended. I B [37]\nInflow cannula placement in the inferior left ventricular wall may be considered. IIb C\nInflow cannula placement in the lateral left ventricular free wall is not recommended. III C [37]\nApical cuff positioning\nApical cuff affixing with the sew first and then core technique, without other intraventricular manipulation necessary, is recommended. I C [37, 251]\nApical cuff affixing with the sew first and then core technique with interrupted pledgeted sutures or continuous suture should be considered. IIa C [251, 252]\nApical cuff affixing with the core first and then sew technique is recommended if intraventricular procedures, e.g. thrombus removal, mitral valve repair, are necessary. I C [37, 251]\nIn the setting of acute left ventricular myocardial infarction due to friable tissue, the sew first and then core technique with use of circular reinforcement strips and surgical glue may be considered. IIb C [251]\nApical cuff affixing with the core first and then sew technique with interrupted pledgeted reverse sutures may be considered. IIb C [251]\nIn the setting of hypertrophic or non-compaction cardiomyopathies, a partial intracavitary excision prior to the apical cuff affixing may be considered. IIb C [253, 254]\nIn the setting of acute left ventricular myocardial infarction with friable tissue of the apex, the use of temporary mechanical circulatory support may be considered to defer a long-term mechanical circulatory support implant. IIb C\nImplantable left ventricular assist device: outflow graft\nPerforming the outflow graft anastomosis on the ascending aorta is recommended. I C [37, 247]\nPerforming the outflow graft-ascending aortic anastomosis at a 45° angle should be considered to reduce the risk of late aortic insufficiency. IIa C [37, 247]\nThe use of surgical glue to secure the haemostasis of the graft-aorta anastomosis may be considered. IIb C [37]\nUsing the longitudinal line marker on the outflow graft to avoid twisting is recommended. I C [37]\nPositioning the outflow graft along the inferior right ventricular surface and between the right atrium and pericardium to avoid crossing the right ventricular outflow tract should be considered. IIa C\nPositioning the outflow graft through the transverse sinus onto the posterolateral aspect of the ascending aorta may be considered. IIb C [255]\nImplantable left ventricular assist device: alternative implant strategy/left thoracotomy approach\nAn intrapericardial course of the outflow graft in patients without previous cardiac surgical procedures is recommended. I C [37, 247]\nThe outflow graft anastomosis to the descending aorta may be considered in redo patients and patients with a severely calcified ascending aorta. IIb C [152–154, 256, 257]\nA left pleural cavity course of the outflow graft in redo implants with the anastomosis on the ascending aorta may be considered. IIb C\nIn redo implants or for patients in whom an aortic anastomosis is not amenable, anastomosis of the outflow graft to the axillary artery may be considered. In this scenario, distal banding of the axillary artery to avoid hyperperfusion may be considered. IIb C [153, 258]\nDriveline externalization\nThe course of the driveline with an intermediate incision (C-shape) to maximize the pump-to-exit site distance and to alleviate traction forces may be considered. IIb C [259]\nA partial course of the driveline through the rectus abdominis muscle to enhance the barrier for infection is recommended. I C [260]\nIt is recommended that the portion of the driveline covered in velour is completely intracorporeal. I C [259, 260]\nAir embolism prevention\nCarbon dioxide insufflation within the surgical field is recommended. I B [261, 262]\nHaving the patient in the Trendelenburg position at the time of de-airing may be considered. IIb C [37]\nLiberal de-airing via the outflow graft is recommended with on-pump surgery. I C [37]\nOversewing or glue application on the outflow graft de-airing spot to obviate late bleeding in patients having anticoagulation therapy may be considered. IIb C\nCareful de-airing strategy in off-pump implantation should be considered. IIa C [263]\nActive suction (needle venting) may be considered. IIb C\nAlternative implant surgical strategy\nLeft anterior thoracotomy at a level of the apex validated by echocardiography or computed tomography is recommended. I C [151–154]\nA partial upper sternotomy for the outflow graft anastomosis may be considered. IIb C [151, 152, 154]\nA right lateral thoracotomy for the outflow graft anastomosis may be considered. IIb C [151, 153]\nAn alternative implant strategy with the outflow graft tunnelled via pleural cavities in redo implants without the need for major concomitant procedures may be considered. IIb C\nIn patients with a history of cardiac surgery through a median sternotomy and who do not require concomitant cardiac surgery other than implantation of long-term mechanical circulatory support, implantation through a left lateral thoracotomy with connection of the outflow graft to the descending aorta may be considered. IIb C\nClosing surgical operation field considerations\nLiberal use of chest and pleural drains is recommended. I C [37]\nIn the case of major coagulopathy, a provisional chest closure with surgical packing may be considered. IIb C [264]\nIn patients with the prospect of a heart transplant, strategies to limit adhesions during implantation should be considered. IIa C\nBiventricular support\nUse of temporary short-term right heart support to allow for a subsequent explant without sternal reopening should be considered. Various possibilities can be considered: cannulation of the right atrium via the femoral vein for blood inflow and for blood return cannulation of vascular graft attached to the pulmonary artery or cannulation through the jugular vein. An additional option may be an endovascular microaxial pump inserted into pulmonary artery. IIa C [265]\nFor implantable right ventricular assist device support, insertion of the inflow cannula insertion into the right atrium should be considered. IIa C [265, 266]\nFor implantable right ventricular assist device support, insertion of the inflow cannula into the right ventricle may be considered. IIb C [266, 267]\nLong-term paracorporeal support\nApical cannulation of the left ventricle should be considered for the left side of the pump. IIa C [188]\nIn patients with restrictive/obstructive cardiomyopathy, cannulation in the left atrium may be considered. IIb C [268]\nTotal artificial heart\nAn atrial connection at the level of the atrioventricular valves and outflow grafts connected to the great vessels are recommended. I C [192, 193, 196, 206, 269, 270]\nLong-term mechanical circulatory support explant\nComplete circulatory support system explant is recommended in cases of active device infection or in patients at a high risk of infective complications. I C [271]\nAfter mechanical circulatory support explant for infection, stabilization with temporary mechanical circulatory support in conjunction with comprehensive antimicrobial therapy may be considered as a bridge to reimplantation. IIb C [263]\nAfter myocardial recovery without signs of infection, removal of the pump with a dedicated titanium sintered plug, outflow graft ligation and removal of the driveline should be considered where possible. IIa C [267, 272]\nAfter heart recovery without signs of infection, decommissioning with outflow graft ligation or endovascular occlusion with partial removal/internalization of the driveline may be considered. IIa C [273, 274]\nLT-MCS: long-term mechanical circulatory support."}