388 
SURGERY AND TRANSPLANTATION 
Figure 2. — Operative procedure for LVAD implantation 
in calves. 
1. Outflow Dacron graft anastomosis to descending 
aorta. 
2. Atrial purse-string suture. 
3. Apical Silastic ring and controlling purse-string 
suture. 
tion. The distal balloon was deflated and the 
catheter was withdrawn from the heart. Pump- 
ing was begun immediately. Despite the use of 
the purse-string suture and of the two balloons 
to control bleeding during the implantation, 
blood loss with this method was considerable. 
In subsequent procedures the double-balloon 
catheter has been replaced by a #20 single- 
balloon Foley catheter (Bardex®, C. R. Bard, 
Inc., Murray Hill, New Jersey). The pump is 
flushed with carbon dioxide through the inflow 
tube. The entire operative field is flooded with 
COo from a second line. The catheter is passed 
through the left atrium into the ventricle and 
the balloon inflated in the apex as in the earlier 
procedures. A circular section of apical myo- 
cardium is excised while blood loss is controlled 
by the intraventricular balloon (Figure 3). The 
inflow tube of the pump is inserted into the 
ventricle as the single balloon is deflated and 
withdrawn. When COo ceases bubbling through 
Figure 3. — Operative procedure for LVAD implantation 
in calves. 
4. Single-balloon Foley catheter. 
5. Excision of apical myocardium with circular 
coring knife. 
the aortic Dacron graft and blood starts to ap- 
pear the graft clamp is slowly released and 
pumping is initiated (Figure 4). 
This modified technique has markedly de- 
creased blood loss, since occlusion of the area 
of resected myocardium is virtually uninter- 
rupted during insertion of the left ventricular 
assist device inflow tube, rather than being in- 
terrupted twice in the earlier technique. In 
addition, fiushing of the pump with CO2 via the 
inflow tube combined with COo flooding of the 
operative field has proved effective in prevent- 
ing coronary air embolism. 
SUMMARY 
The major operative hazards encountered 
early in our studies of left ventricular assist 
device implantation in the calf were (1) inade- 
quate ventilation, (2) the marked irritability of 
the calf's heart and consequent occurrence of 
ventricular fibrillation during cardiac manipu- 
lation, (3) massive blood loss, and (4) coronary 
air embolism. 
Technical procedures have been developed 
and applied with success in overcoming these 
problems. (1) Premedication with atropine sul- 
