**6. Conclusions**

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 decreased hospital cost. However it remains a matter of debate if these approaches offer advantages in comparison to standard full-sternotomy access in LVAD implantation procedure. An undeniable advantage of the minimally invasive implantation technique is the lack of adhesions at the time of transplant, which facilitates heart transplantation and also reduces ischemia time resulting in improved graft performance. The use of off-pump LVAD implantation approach allows the avoidance of cardiopulmonary bypass and will decrease the incidence of vasoplegia and coagulopathy postoperatively. Another advantage of a less invasive approach is that the right ventricle remains in its natural position, as the surrounding pericardium stays intact and the right ventricular function remains sustained; in this way right ventricular failure is passively avoided [23]. The progressive miniaturization of VADs has provided a further boost to the research of mini-invasive implantation techniques, and future research will tend towards ever greater device miniaturization. LVAD implantation by minimally invasive procedure is feasible and safe; LVAD implantation without the use of CPB has the potential to minimize postoperative complication such as excessive bleeding during implantation without compromising hemodynamics. By minimizing the needs for blood transfusions, patients have decreased exposure to blood antigens which ultimately reduces the risk of sensitization in BT patients. The upcoming advancement of LVAD technology and miniaturization of mechanical circulatory support will only further advance the success of LVAD surgery and will benefit more patients especially with the rapidly growing heart failure population worldwide.
