Diaphragmatic implantation of the HeartWare ventricular assist device

The HeartWare (HeartWare Inc., Framingham, MA) ventricular assist device (HVAD) is designed to be implanted with the pump in the pericardial space and its integrally attached inflow cannula in the left ventricle. The uniquely incorporated inflow cannula was originally designed to be inserted into the diaphragmatic surface of the heart, allowing the pump to sit on the flattened diaphragmatic surface. Commonly, however, the inflow cannula is placed through the usual left ventricular assist device insertion site, anterolateral to the left ventricular apex. We describe the original, intended technique for inflow cannula insertion and HVAD placement on the diaphragmatic surface of the left ventricle. Our experience has confirmed that this placement results in the optimal left ventricular position, with orientation of the inlet cannula parallel to the short axis of the left ventricle and anterior to the papillary muscle insertion. This approach should protect against inflow obstruction and endocardial contact, with resulting arrhythmias. In addition, this position results in lateral placement of the outflow graft, avoiding the anterior and retrosternal surface of the right ventricle.