How to do it: tips and tricks of minimal-invasive HVAD ？ implantation—the lateral approach

Chronic end-stage heart failure (CHF) is a major healthcare problem with rapidly growing incidences in Europe and the United States (1). With decreasing cardiac transplant rates worldwide, alternative treatment methods become increasingly important. The role and application of mechanical circulatory support (MCS) devices such as left ventricular assist devices (LVADs) for the therapy of CHF has increased worldwide (2-5). Novel technologies and surgical experience have played a key role in VAD-related successes. The most significant improvement in LVADs has been their essential miniaturization, which allows their implantation with less invasive surgical procedures (2-4,6-10). It is already known that minimally invasive surgical (MIS) procedures result in reduced wound size, ameliorated blood loss, shorter hospitalization duration, and improved cost-effectiveness. The reduction in post-operative complications has contributed to improved survival rates. This has led to considerably improved long-term outcomes over time (6,7,9-12). With further miniaturization of LVADs, the application of MIS techniques for implantations is likely to increase, giving rise to the need for well-established surgical approaches. The start of the development of the MIS-LVAD implantation technique for the HVAD as well as for other devices was worldwide first performed at Hannover Medical School in 2011 (2). The publication of this novel technique is the mark of a clinical paradigm shift in the therapy of patients with permanent ventricular assist devices. The implantation technique includes an upper hemi-sternotomy combined with anterior-lateral thoracotomy and is developed to reduce complication rates (trauma size, postoperative blood loss, right heart failure), thereby allowing earlier recovery and better survival. Several modifications of this approach have been described for LVAD implantation (2,6,7,13-15). HVAD implantation with this technique is acknowledged worldwide as a procedure to treat left ventricular failure (2,6). The HeartWare ventricular assist device or HVAD (Medtronic, Minnesota, MN, USA) is a miniaturized, continuous-flow, centrifugal, implantable VAD (16). The inflow is in the apex of the left ventricle and the outflow on the aorta ascendens, while the pump is operated by a percutaneous driveline. The current article describes the technical aspects and characteristic features of less invasive HVAD implantation in detail