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CLINICAL SUMMARY A33-year-oldman diagnosedwith familial dilated cardiomyopathy whose disease was being managed with medical therapy was deteriorating clinically. He underwent assessment for heart transplantation and was accepted on the waiting list. Echocardiography showed severely dilated left and right ventricles with poor systolic function, severe tricuspid regurgitation, and a patent foramen ovale. In view of deteriorating renal and hepatic function despitemaximummedical therapy including inotropic support, it was decided to implant a ventricular assist device as a bridge to transplant. At surgery, the patient was put on cardiopulmonary bypass (CPB) via aortic and bicaval cannulation. The operation was performed on a beating heart with the foramen ovale being closed first, followed by the tricuspid annuloplasty using a 36 mm ring. The HeartWare ventricular assist device (HeartWare International Inc, Framingham, Mass) was implanted in a routine fashion. The connective tissue rostral to the superior vena cava (SVC), caudal to the azygos vein was dissected and the outflow graft was passed under the SVC, in close proximity to the right pulmonary artery (Figure 1). The length of the graft was adjusted and it was anastomosed laterally to the ascending aorta. After additional de-airing, the HVAD was started with flows> 5 L/ minute. A computed tomography (CT) scan performed after a week showed ideal positioning of the outflow graft situated beneath the SVC without kinking or compromising the SVC caliber (Figure 2). The patient made rapid recovery and was discharged after 3 weeks.

Tunneling of ventricular assist device outflow graft rostral to superior vena cava