Recommendations   Class   Level   References
Use of circulatory assistance during implantation: implant strategy
The use of cardiopulmonary bypass during implantation of a long-term mechanical circulatory support device should be considered.  IIa  C  [37, 138, 141, 145, 247]
In 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]
In off-pump mechanical circulatory support implantation, secured vascular access for bail-out cardiopulmonary bypass is recommended.  I  C  [249, 250]
Mechanical circulatory support site preparation
For non-intrapericardial devices, creation of the pump pocket by left hemidiaphragm transection to accommodate the pump is recommended.  I  C  [37]
For 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]
Implantable left vascular assist device—inflow cannula placement
Inflow cannula placement into the left ventricle is recommended.  I  A  [37, 138]
The use of transoesophageal echocardiography to check the inflow cannula position is recommended.  I  C  [37]
Placement of the inflow cannula parallel to the septum is recommended.  I  B  [37]
Inflow cannula placement in the inferior left ventricular wall may be considered.  IIb  C
Inflow cannula placement in the lateral left ventricular free wall is not recommended.  III  C  [37]
Apical cuff positioning
Apical cuff affixing with the sew first and then core technique, without other intraventricular manipulation necessary, is recommended.  I  C  [37, 251]
Apical cuff affixing with the sew first and then core technique with interrupted pledgeted sutures or continuous suture should be considered.  IIa  C  [251, 252]
Apical 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]
In 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]
Apical cuff affixing with the core first and then sew technique with interrupted pledgeted reverse sutures may be considered.  IIb  C  [251]
In 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]
In 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
Implantable left ventricular assist device: outflow graft
Performing the outflow graft anastomosis on the ascending aorta is recommended.  I  C  [37, 247]
Performing 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]
The use of surgical glue to secure the haemostasis of the graft-aorta anastomosis may be considered.  IIb  C  [37]
Using the longitudinal line marker on the outflow graft to avoid twisting is recommended.  I  C  [37]
Positioning 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
Positioning the outflow graft through the transverse sinus onto the posterolateral aspect of the ascending aorta may be considered.  IIb  C  [255]
Implantable left ventricular assist device: alternative implant strategy/left thoracotomy approach
An intrapericardial course of the outflow graft in patients without previous cardiac surgical procedures is recommended.  I  C  [37, 247]
The 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]
A left pleural cavity course of the outflow graft in redo implants with the anastomosis on the ascending aorta may be considered.  IIb  C
In 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]
Driveline externalization
The 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]
A partial course of the driveline through the rectus abdominis muscle to enhance the barrier for infection is recommended.  I  C  [260]
It is recommended that the portion of the driveline covered in velour is completely intracorporeal.  I  C  [259, 260]
Air embolism prevention
Carbon dioxide insufflation within the surgical field is recommended.  I  B  [261, 262]
Having the patient in the Trendelenburg position at the time of de-airing may be considered.  IIb  C  [37]
Liberal de-airing via the outflow graft is recommended with on-pump surgery.  I  C  [37]
Oversewing or glue application on the outflow graft de-airing spot to obviate late bleeding in patients having anticoagulation therapy may be considered.  IIb  C
Careful de-airing strategy in off-pump implantation should be considered.  IIa  C  [263]
Active suction (needle venting) may be considered.  IIb  C
Alternative implant surgical strategy
Left anterior thoracotomy at a level of the apex validated by echocardiography or computed tomography is recommended.  I  C  [151–154]
A partial upper sternotomy for the outflow graft anastomosis may be considered.  IIb  C  [151, 152, 154]
A right lateral thoracotomy for the outflow graft anastomosis may be considered.  IIb  C  [151, 153]
An 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
In 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
Closing surgical operation field considerations
Liberal use of chest and pleural drains is recommended.  I  C  [37]
In the case of major coagulopathy, a provisional chest closure with surgical packing may be considered.  IIb  C  [264]
In patients with the prospect of a heart transplant, strategies to limit adhesions during implantation should be considered.  IIa  C
Biventricular support
Use 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]
For implantable right ventricular assist device support, insertion of the inflow cannula insertion into the right atrium should be considered.  IIa  C  [265, 266]
For implantable right ventricular assist device support, insertion of the inflow cannula into the right ventricle may be considered.  IIb  C  [266, 267]
Long-term paracorporeal support
Apical cannulation of the left ventricle should be considered for the left side of the pump.  IIa  C  [188]
In patients with restrictive/obstructive cardiomyopathy, cannulation in the left atrium may be considered.  IIb  C  [268]
Total artificial heart
An 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]
Long-term mechanical circulatory support explant
Complete 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]
After 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]
After 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]
After 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]