**2. Standard and alternative inflow cannula placement**

The LVAD relies on three principal blood-contacting components to function: the inflow cannula (IC) – which draws blood from the left side of the heart; the pump – which propels the blood; and the outflow graft (OG) – which returns the blood to the systemic circulation [3, 4]. The placement and position of the IC, however, are crucial considerations for ensuring proper LVAD function, optimal cardiac support, and patient outcomes [3, 5–9]. The left ventricle's (LV) true apex has historically been considered the best placement position of the LVAD's IC and is, therefore, standard [1, 5, 10] (**Table 1**). Several factors rationalize this: IC's placement through the true apex ensures reproducible surgical placement technique. While there may be anatomical variations among patients, the true apex remains a consistently identifiable anatomical landmark [1, 5, 10]. Given its pointed structure and relative anatomical isolation, the LV apex allows for straightforward insertion and secure cannula anchoring. The area is also less prone to hypertrophy, providing a consistent myocardial texture for cannula insertion. From a hemodynamic standpoint, using the true apex as an IC placement entry point ensures the IC's physiological orientation, aligning it with the direction of the physiological blood flow towards the apex [6, 7]. This facilitates more direct flow from the mitral valve to the IC, enhances the device's efficiency, and minimizes blood stasis [6, 8]. The IC must point towards the mitral valve [7] so that its long axis matches the long axis (natural flow axis) of the LV, ensuring that the inflow cannula's orientation is in synchrony with the LV's natural flow trajectory [10, 11]. It also facilitates the direction of the IC that best accommodates the anticipated reductions in LV chamber size occurring over time [8]. Angulation of the IC off-axis towards the interventricular septum or left ventricular free wall may cause intermittent partial occlusion of the IC and suction events, which may lead to poor flow into the LVAD with consequent poor ventricular unloading


#### **Table 1.**

*Left ventricular assist device implantation with inflow cannula placement at the true apex.*
