**3. Minimally invasive LVAD implantation (off-pump technique)**

Minimally invasive implantation techniques require patient assessment and evaluation. Echocardiography helps identify patients with valvular disease who need concomitant valve procedure and would preferably be approached through a standard midline sternotomy. In the presence of left ventricle thrombus, an onpump approach should be performed for thrombus removal. Noncontrast chest computed tomography is helpful in determining which intercostal space to be used and whether an anterolateral or lateral mini-thoracotomy should be utilized (most of the time, fifth or sixth intercostal space). Chest computed tomography will also be useful for the evaluation of the outflow aortic anastomosis site and to rule out aortic calcification and aneurysm [12].

The LVAD implantation is divided into three steps:


The minimally invasive implantation procedure could be done for the first two steps.
