**5. Discussion**

Implantable LVADs have revolutionized the treatment of end-stage heart failure [2, 47]. The placement of the IC into the true LV apex and the OG at the ascending aorta have become standards in LVAD implantation techniques with implications in ways that go beyond simple surgical convenience - the optimal positioning of these components has a significant impact on patient outcomes and the efficiency of the LVAD system [1, 2, 47, 48]. However, modifications to the standard surgical techniques of IC and OG placement exploiting their different landing sites and attachment methods can be made to address particular patient demands [10]. Such alternative techniques might also gain popularity as our knowledge of the dynamics and physiology of heart failure advances, and new technical advancements take hold. Moreover, avoiding access to the ascending aorta in the cases of alternative OG placement techniques offers the convenience of a quasi-virgin mediastinum, which should ease future reoperation and improve outcomes in heart transplant recipients [39, 45, 49]. Big, granular data on long-term outcomes with alternative IC and OG placement techniques is not available yet, and standard implantation sites remain predominant in clinical practice due to their proven efficacy, as evidenced by decades of clinical experience [1]. Nevertheless, the vast heterogeneity of patient conditions and clinical scenarios necessitates the consideration of alternative and unconventional approaches to device placement, which provide invaluable solutions in situations when patient-specific variables prevent routine implantation [1, 10, 37]. These approaches are not merely alternatives, but often tailored strategies devised in the face of challenges that the standard practices cannot address.

Further detailed research assessing the standard and alternative LVAD implantation techniques should provide insights that facilitate further refinements in these approaches that translate into improvements in patient outcomes. As the field continues to advance, it is paramount to prioritize patient-specific considerations while pursuing optimization, durability, and safety.
