An 8 cm left sub-areolar thoracotomy was performed as the working port. The pericardium was opened vertically over the left ventricular apex and suspended with retraction sutures.
Using 3-0 polypropylene pledgeted sutures, the apical cuff was secured to the left ventricular (LV) apex. The driveline was tunneled subcostally and exteriorized on the lateral abdominal wall. The apex was cored, and the inflow cannula was inserted and secured.
The outflow graft was directed toward the ascending aorta in the standard fashion. After applying a partial occluding clamp, an aortotomy was performed. An end-to-side anastomosis between the left ventricular assist device (LVAD) outflow graft and the ascending aorta was completed using 4-0 polypropylene suture. After meticulous deairing of the LV, pump, and graft, the clamp was removed, and the LVAD was initiated.
An 8 cm right sub-areolar working port was created, and the robotic surgical system was docked. Arm 1 (DeBakey forceps) was positioned in the second intercostal space, lateral to midclavicular line. Arm 2 (30° camera) was inserted through the working port, while Arm 3 (scissors/needle holder) was placed in the sixth intercostal space, anterior axillary line.
The pericardium over the ascending aorta and right atrium was opened robotically. A plane was developed between the ascending aorta and main pulmonary artery.
The main pulmonary artery was opened vertically, and the right ventricular assist device (RVAD) outflow graft was anastomosed end-to-side to the pulmonary artery using 4-0 polypropylene suture. Retrograde deairing was performed, and a bulldog clamp was applied.
The RVAD inflow cuff was prepared using layered Teflon felt to achieve appropriate cannula depth. Using 4-0 polypropylene pledgeted sutures, the cuff was anchored to the right atrium.
The RVAD driveline was tunneled subcostally and exteriorized laterally. After coring the right atrium, the inflow cannula was inserted. The outflow graft was connected to the pump, followed by attachment of the pump to the atrial cuff. The RVAD was initiated after deairing.
Completion and Outcomes
Cardiopulmonary bypass was successfully weaned on minimal vasoactive support. Both LVAD and RVAD demonstrated satisfactory flows.
The patient was transferred to the intensive care unit (ICU) with stable hemodynamics and was discharged home after an uneventful postoperative course.
Disclosure
Dr. Khaliel is a consultant for Abbott.
This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.
References
- Farag J, Woldendorp K, McNamara N, Bannon PG, et al. Contemporary outcomes of continuous-flow biventricular assist devices. Ann Cardiothorac Surg 2021; 10: 311–328.
- Jasmine S, Gunes D, Axel H, et al. Implantation of two HeartMate 3s in the setting of a Total Artificial Heart. Operative techniques in thoracic and cardiovascular surgery 26:67-80,2020.
- Hrvoje G, Davor M, Kristina K,et al. HeartMate 3 biventricular support exceeding 4.5 years. ESC Heart Failure 2023; 10 : 2094-2098.
- Ahmed MM, Jacobs JP, Meece LE, Jeng EI, Bleiweis MS, Cantor RS, Singletary B, Kirklin JK, Slaughter MS. Timing and Outcomes of Concurrent and Sequential Biventricular Assist Device Implantation: A Society of Thoracic Surgeons Intermacs Analysis. Ann Thorac Surg. 2023 Aug;116(2):383-390.
- David P, Hao A, Jorge S, et al. A case series of Biventricular Circulatory Support using Two Ventricular Assist Devices: A Novel Operative Approach. Ann Thorac Surg 2015;100:75-7.
- Khalpey Z, Bin Riaz I, Marsh KM, et al. Robotic Left Ventricular Assist Device Implantation Using Left Thoracotomy Approach in Patients with Previous Sternotomies. ASAIO J. 2015 Nov-Dec;61(6):e44-6.
- Norihiko I, Go W. Robot-assisted cardiac surgery. Ann Thorac Cardiovasc Surg 2015;21:322–8.
- Vistarini N, et al. Robotic cardiac surgery: a comprehensive review of the current literature. Ann Cardiothorac Surg. 2016;5(1):1-15.
- Ayers B, Sagebin F, Wood K, Barrus B, Thomas S, Storozynsky E, et al. Complete sternal-sparing left ventricular assist device implantation is associated with improved postoperative mobility and functional independence compared with full sternotomy. Eur J Cardiothorac Surg. 2021.
Disclaimer
The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.
430 views on Vimeo
