Sternotomy Sparing Left Ventricular Assist Device Implantation with ECMO as Circulatory Support

This video illustrates an alternative technique for the implantation of a left ventricular assist device (LVAD) via a bilateral mini-thoracotomy instead of a standard median sternotomy. This approach has some theoretical advantages, such as: less surgical trauma and inflammation, better compliance of the thorax, improved pulmonary function, and better right heart protection. Therefore, this approach can lead to a faster recovery with reduced overall morbidity and mortality. Additional improvement is achieved by using ECMO as circulatory support during implantation of the LVAD, as this reduces inflammation and volume shifts.

Two mini-thoracotomies are performed. One is performed on the left-sided 4th or 5th intercostal space, for cannulation of the left ventricular apex (exact localization assessed by transthoracic echocardiography). The other mini-thoracotomy is performed on the right site in the 2nd intercostal space in order to gain access to the ascending aorta for central ECMO cannulation and the outflow graft anastomosis. After opening the pericardium, coring the left ventricular apex and placing the inflow cannula into it, the outflow graft is pulled through the pericardium with an umbilical tape and is anastomosed to the ascending aorta. The driveline is tunneled to the right epigastrium. The LVAD can then be started, and the patient is weaned from ECMO support under transesophageal echocardiography control.