**4. Minimally invasive implantation of inflow cannula and pump insertion**

There are two types of minimally invasive approaches to implant the VAD and the inflow cannula; the first one we describe is a left subcostal incision (**Figure 1**). This kind of approach was used mainly for the LVAD HeartMate II that is the largest of the contemporary LVAD devices [13]. A subcostal incision is used, running along the left-sided rib cage. After division of the abdominal muscles, preparation anteriorly to the diaphragm is performed. Through this access, the pericardium can be divided and the left ventricular apex easily identified [14].

The second one is via left anterior thoracotomy at the fifth or sixth intercostal space (**Figure 2**). Intraoperative echocardiography is used to identify the LV apex location and to determine the optimal location and intercostal space for left thoracotomy. A 6 cm thoracotomy incision is usually performed in the fifth or sixth intercostal space; upon entering the chest, the pericardium is identified and divided, and a pericardial cradle is created with pericardial sutures to expose the LV apex [12].

In case of an off-pump VAD placement, there are techniques that can be used to reduce the use of blood. Reliant on the experience in transcatheter valve implantation by the use of rapid pacing, multiple authors reported inserting off-pump LVAD with rapid pacing for the insertion [15]. Implantation of LVAD with nonfibrillatory technique by administrating of an intravenous bolus of adenosine to induce a short bradycardic arrest during off-pump LVAD placement was also described [16], in order to reduce blood loss by reducing both the volume of the blood ejected from the heart during LVAD implant (reduction in blood pressure) and decreasing the heartbeats. In this method adenosine mediates pulmonary vasodilatation, which may reduce pulmonary resistance and protect the right ventricle function [17].

**5**

*Minimally Invasive Ventricular Assist Device Surgery DOI: http://dx.doi.org/10.5772/intechopen.90911*

**5. Outflow graft insertion**

*Left anterior thoracotomy at fifth or sixth intercostal space.*

descending aorta [18].

**Figure 2.**

This step of LVAD implantation technique could be done by multiple ways in different locations: right mini-thoracotomy, split upper hemi-sternotomy, axillary and subclavian arteries, supraceliac abdominal aorta, innominate artery, and

The most commonly used technique for on-pump minimally invasive strategy of LVAD implantation is through upper hemi-sternotomy (**Figure 3**) [19]. A 4 cm upper hemi-sternotomy is performed to expose the ascending aorta; if CPB is planned, the distal ascending aorta could be used for arterial cannulation to assure adequate cerebral perfusion, and femoral vein is used for a percutaneous venous cannulation. It can be associated with either inflow pump incisions; for the majority of patients, the outflow graft is tunneled and passed within the pericardium and anastomosed to the proximal ascending aorta (**Figure 4**). The OG could be passed in the anterior mediastinum behind the sternum in case of previous sternotomy. Another way to implant the OG is through right mini-thoracotomy (**Figure 5**). This kind of approach can be used if the ascending aorta demonstrated a right-side curvature on preoperative chest tomography. A 4–6 cm incision is made at second to third intercostal spaces which allows access to the ascending aorta to perform the outflow anastomosis: after passing the outflow graft from the left thoracotomy to the right thoracotomy, a side-biting clamp is attached on the ascending aorta, and after adequate incision of the aorta, the graft is anastomosed in the usual manner. Another method is the combination of the previous two approaches through an upper hemi-sternotomy with right hemi-thoracotomy J-shape incision (**Figure 6**). At least left subclavian outflow graft anastomosis has been increasingly utilized for patient's anatomy when OG anastomosis to the ascending or the descending aorta is prohibited (**Figure 7**). The OG is tunneled through the right or the left pleural cavity and passed through the second intercostal space to be anastomosed to the subclavian artery (**Figure 8**). If this technique is used, attention must be paid to the eventual

**Figure 1.** *Left subcostal incision.*

*Minimally Invasive Ventricular Assist Device Surgery DOI: http://dx.doi.org/10.5772/intechopen.90911*

*Cardiac Surgery Procedures*

**insertion**

apex [12].

ventricle function [17].

**4. Minimally invasive implantation of inflow cannula and pump** 

be divided and the left ventricular apex easily identified [14].

There are two types of minimally invasive approaches to implant the VAD and the inflow cannula; the first one we describe is a left subcostal incision (**Figure 1**). This kind of approach was used mainly for the LVAD HeartMate II that is the largest of the contemporary LVAD devices [13]. A subcostal incision is used, running along the left-sided rib cage. After division of the abdominal muscles, preparation anteriorly to the diaphragm is performed. Through this access, the pericardium can

The second one is via left anterior thoracotomy at the fifth or sixth intercostal

In case of an off-pump VAD placement, there are techniques that can be used to reduce the use of blood. Reliant on the experience in transcatheter valve implantation by the use of rapid pacing, multiple authors reported inserting off-pump LVAD with rapid pacing for the insertion [15]. Implantation of LVAD with nonfibrillatory technique by administrating of an intravenous bolus of adenosine to induce a short bradycardic arrest during off-pump LVAD placement was also described [16], in order to reduce blood loss by reducing both the volume of the blood ejected from the heart during LVAD implant (reduction in blood pressure) and decreasing the heartbeats. In this method adenosine mediates pulmonary vasodilatation, which may reduce pulmonary resistance and protect the right

space (**Figure 2**). Intraoperative echocardiography is used to identify the LV apex location and to determine the optimal location and intercostal space for left thoracotomy. A 6 cm thoracotomy incision is usually performed in the fifth or sixth intercostal space; upon entering the chest, the pericardium is identified and divided, and a pericardial cradle is created with pericardial sutures to expose the LV

**4**

**Figure 1.**

*Left subcostal incision.*

**Figure 2.** *Left anterior thoracotomy at fifth or sixth intercostal space.*

#### **5. Outflow graft insertion**

This step of LVAD implantation technique could be done by multiple ways in different locations: right mini-thoracotomy, split upper hemi-sternotomy, axillary and subclavian arteries, supraceliac abdominal aorta, innominate artery, and descending aorta [18].

The most commonly used technique for on-pump minimally invasive strategy of LVAD implantation is through upper hemi-sternotomy (**Figure 3**) [19]. A 4 cm upper hemi-sternotomy is performed to expose the ascending aorta; if CPB is planned, the distal ascending aorta could be used for arterial cannulation to assure adequate cerebral perfusion, and femoral vein is used for a percutaneous venous cannulation. It can be associated with either inflow pump incisions; for the majority of patients, the outflow graft is tunneled and passed within the pericardium and anastomosed to the proximal ascending aorta (**Figure 4**). The OG could be passed in the anterior mediastinum behind the sternum in case of previous sternotomy.

Another way to implant the OG is through right mini-thoracotomy (**Figure 5**). This kind of approach can be used if the ascending aorta demonstrated a right-side curvature on preoperative chest tomography. A 4–6 cm incision is made at second to third intercostal spaces which allows access to the ascending aorta to perform the outflow anastomosis: after passing the outflow graft from the left thoracotomy to the right thoracotomy, a side-biting clamp is attached on the ascending aorta, and after adequate incision of the aorta, the graft is anastomosed in the usual manner. Another method is the combination of the previous two approaches through an upper hemi-sternotomy with right hemi-thoracotomy J-shape incision (**Figure 6**). At least left subclavian outflow graft anastomosis has been increasingly utilized for patient's anatomy when OG anastomosis to the ascending or the descending aorta is prohibited (**Figure 7**). The OG is tunneled through the right or the left pleural cavity and passed through the second intercostal space to be anastomosed to the subclavian artery (**Figure 8**). If this technique is used, attention must be paid to the eventual

**Figure 3.** *Upper hemi-sternotomy.*

#### **Figure 4.**

*The OG anastomosed to the proximal ascending aorta.*

compression of the OG by adjacent structures; it is necessary to reduce the possibility of creating excess flow to the arm and also the turbulence of the flow in case of mobilization of the arm. Banding of the subclavian artery is mandatory if there is a mean pressure difference of more than 20 mmHg to avoid excessive blood flow to the arm [20].

Two further types of approaches are used less frequently: single left thoracotomy incision with descending aorta anastomosis (**Figure 9**) and supraceliac

**7**

**Figure 6.**

*Right hemi-sternotomy J-shape incision.*

**Figure 5.**

*Right hemi-thoracotomy.*

abdominal aorta anastomosis (**Figure 10**). In the first approach, the inferior pulmonary ligament is freed to optimize exposure; the OG is placed in the left pulmonary fissure, measured, and anastomosed end to side to the descending aorta or the aortic arch using a partial cross clamp [21]. The second one is used by making left subcostal incision and dividing the diaphragm to make the pocket. This allows the LVAD to be implanted on the diaphragmatic surface of

*Minimally Invasive Ventricular Assist Device Surgery DOI: http://dx.doi.org/10.5772/intechopen.90911*

*Minimally Invasive Ventricular Assist Device Surgery DOI: http://dx.doi.org/10.5772/intechopen.90911*

**Figure 5.** *Right hemi-thoracotomy.*

*Cardiac Surgery Procedures*

**6**

arm [20].

**Figure 4.**

*The OG anastomosed to the proximal ascending aorta.*

**Figure 3.**

*Upper hemi-sternotomy.*

compression of the OG by adjacent structures; it is necessary to reduce the possibility of creating excess flow to the arm and also the turbulence of the flow in case of mobilization of the arm. Banding of the subclavian artery is mandatory if there is a mean pressure difference of more than 20 mmHg to avoid excessive blood flow to the

Two further types of approaches are used less frequently: single left thoracotomy incision with descending aorta anastomosis (**Figure 9**) and supraceliac

**Figure 6.** *Right hemi-sternotomy J-shape incision.*

abdominal aorta anastomosis (**Figure 10**). In the first approach, the inferior pulmonary ligament is freed to optimize exposure; the OG is placed in the left pulmonary fissure, measured, and anastomosed end to side to the descending aorta or the aortic arch using a partial cross clamp [21]. The second one is used by making left subcostal incision and dividing the diaphragm to make the pocket. This allows the LVAD to be implanted on the diaphragmatic surface of

the left ventricle, and the supraceliac aorta is then exposed by extraperitoneal exposure. The outflow is trimmed and anastomosed end to side on the supraceliac aorta [22].

**Figure 7.** *Left hemi-thoracotomy.*

**9**

**6. Conclusions**

*Supraceliac abdominal aorta anastomosis.*

**Figure 10.**

**Figure 9.**

The use of LVAD has increased significantly along with the rapidly expanding heart failure patient population. Like in other cardiac surgical procedures, minimally invasive approaches are becoming more commonly used, also in the field of VAD implantation. Multiple studies have shown minimally invasive cardiac surgery improves outcomes with reduced surgical trauma and complication rates, e.g., postoperative bleeding, reduced blood transfusion requirement, faster recovery rate, and

*Minimally Invasive Ventricular Assist Device Surgery DOI: http://dx.doi.org/10.5772/intechopen.90911*

*Single left thoracotomy incision with descending aorta anastomosis.*

**Figure 8.** *The OG anastomosed to the subclavian artery.*

*Minimally Invasive Ventricular Assist Device Surgery DOI: http://dx.doi.org/10.5772/intechopen.90911*

*Cardiac Surgery Procedures*

aorta [22].

**Figure 7.**

*Left hemi-thoracotomy.*

the left ventricle, and the supraceliac aorta is then exposed by extraperitoneal exposure. The outflow is trimmed and anastomosed end to side on the supraceliac

**8**

**Figure 8.**

*The OG anastomosed to the subclavian artery.*

**Figure 9.** *Single left thoracotomy incision with descending aorta anastomosis.*

**Figure 10.** *Supraceliac abdominal aorta anastomosis.*
