1. Minimally Invasive Implantation: The Procedure of Choice!
Jan D. Schmitto, Ezin Deniz, Sebastian V. Rojas, Simon Maltais, Zain Khalpey, Jasmin S. Hanke, Christina Egger, Axel Haverich 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 21, Issue 1, Pages (March 2016)
DOI: /j.optechstcvs
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2. Figure 1
The surgical procedure starts with a 6-10cm mediosternal skin incision and an upper minimal J sternotomy with extension into the right second-to-third intercostal space.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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3. Figure 2
The pericardium is opened over the ascending aorta only. Cardiopulmonary bypass is established via arterial cannulation of the ascending aorta and venous cannulation of the femoral vein or 2-stage cannulation of the RA, depending on space and surgeon preference.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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4. Figure 3
Transthoracic echocardiography is used to identify the LV apex and place the 7-9cm anterior left chest skin incision (A). A minithoracotomy through the fifth intercostal space is made to expose the apex of the heart. The pericardium is opened near to the apex (B) and the site for epicardial sewing ring is selected by manually poking the apex while visualizing the on the left ventricle on transeosophageal echocardiography.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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5. Figure 4
The HVAD sewing ring is then placed on the apex (A) and secured using teflon-pledged sutures and a 4-0 running prolene suture reinforced with BioGlue or PuraStat.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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6. Figure 5
The center of myocardium inside the ring is incised and cored (A).
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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7. Figure 5
The center of myocardium inside the ring is incised and cored (A).
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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8. Figure 5
Continued LV cavity is inspected for thrombus and the inflow cannulais placed through the sewing ring into the left ventricle (B) and secured.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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9. Figure 5
Continued LV cavity is inspected for thrombus and the inflow cannulais placed through the sewing ring into the left ventricle (B) and secured.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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10. Figure 6
The outflow vascular graft is distally tied and tunneled extrapericardially and retrosternally toward the ascending aorta (A). A partial cross clamp is placed on the ascending aorta. The graft is measured, cut obliquely, and the anastomosis with the ascending aorta is performed using a continuous 4-0 prolene suture through the upper hemisternotomy (B). The driveline is tunneled within the sheath of the rectus muscle in umbilical direction and then subcutaneously to the right or left upper quadrant (C) to decrease infection rates.41
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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11. Figure 7
Standard deairing of the device is performed and the pump is started in situ. The pump speed is gradually increased as the patient is weaned from extracorporeal circulation (A), monitoring vital signs, RV function, and AV-opening (B). An estimated mean pump flow of 5 ± 1l is usually achieved when the left pump is running at 2800 ± 200rpm. (Color version of figure is available online.)
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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12. Figure 7
Continued.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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13. Figure 8
Afterwards a chest tube is placed into the left pleural space, the position of the graft anastomosis and the VAD is finally checked and the 2 small incisions are closed.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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14. Figure 9
Then the patient is transferred to the ICU. The in situ position of the VAD is evaluated on the postoperative X-ray. ICU=intensive care unit.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 65-78DOI: ( /j.optechstcvs )
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