Off Pump Robotic-Assisted LVAD (HeartWare, HVAD) Placement via Left Mini Thoracotomy  David W. Pantino, MD, Zain Khalpey, MD, PhD, FACS  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 22, Issue 1, Pages 68-77 (March 2017) DOI: 10.1053/j.optechstcvs.2017.04.002 Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 1 The patient is placed in the supine position with arms tucked. A double lumen endotracheal tube is inserted. A transesophageal echocardiography (TEE) should be performed to ensure there is no left ventricular (LV) apical thrombus or aortic insufficiency. In this case, the procedure will be done on pump through groin access, and an upper redo sternotomy is performed for aortic exploration. Wire access to the femoral artery and vein is obtained should rapid cardiopulmonary bypass be needed. Rib spaces are counted and marked along the anterior axillary line at the second, fifth, and seventh intercostal spaces. An S5-1 probe is used to identify and mark the LV apex. ICS = intercostal space. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 2 Through a left mini thoracotomy, typically in the fifth intercostal space, the LV apex should be exposed with guidance of an S5-1 probe. With the lung retracted away, the pericardium should then be opened vertically and suspended to the skin edges with silk sutures. An Aztec retractor is used within this window for further exposure. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 3 After the device is prepped on the back table, it is brought onto the field; the intrathoracic portion of the driveline is wrapped with 1-mm Gore-Tex membrane. A tunneling device is used to bring the driveline to a predetermined location on the right side of the patient, lateral to the rectus muscle, midway from the costal margin and anterior superior iliac spine. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 4 With TEE assistance, the LV apex is identified and confirmed with a needle placed at the point parallel with the ventricular septum and in the direction of the mitral valve. The HVAD ring is then sewn into place over the apex with 8 interrupted 3-0 pledgeted Ethibond sutures. BioGlue is placed on the periphery of the ring for hemostasis. Heparin is given for a goal ACT > 480 followed by 12 mg of adenosine or rapid ventricular pacing. With the heart in temporary arrest, the LV apex is cored and a thumb is placed to occlude the apical sewing ring. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 5 The device is attached and secured into place. The device should be isolated from the lungs and surrounding tissue by placing 1-mm Gore-Tex membrane on the inner pericardial surface and the epicardium. This becomes especially important in bridge-to-transplant patients. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 6 The robot is docked from the patient's left side and trocars placed at the second, fifth and seventh intercostal spaces (ICS). The camera port will be at the fifth ICS. The outflow graft is placed extrapericardial along the level of the diaphragm, along the right atrium, and to the level of the sino-tubular junction of the aorta. The pericardium is left intact except for the region overlying the ascending aorta. The graft is clamped at the level of its origin with the LVAD using two mosquito clamps. Before cutting the outflow graft, the graft is allowed to slowly fill and is brought to the desired level on the ascending aorta. The graft should be cut (as depicted by the dotted line) to avoid kinking of the outflow graft. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 7 (A) The patient on single lung ventilation, with the right lung down and robot arms engaged, creates exposure of the ascending aorta. After creating a longitudinal incision in the pericardium overlying the ascending aorta, an exposure stitch is placed in the pericardium to bring the ascending aorta into the field. A stab incision is made at the second ICS through which a nesting Derra clamp can be placed over both sides of the aorta. The outflow graft must be checked to ensure it is lying in the correct anatomic position. (B) With the aorta partially clamped, a robotic knife is used to make a 15 mm incision and the outflow graft is cut and beveled to match. (C) The anastomosis is created using 4-0 Gore-Tex suture. BioGlue is used for hemostasis. The graft is de-aired in two places. First, a 22 g needle is placed at the origin of the outflow graft while the aortic clamp is still in place, allowing de-airing from the LVAD. Second, after the anastomosis is created, a long Pean clamp is placed on the graft followed by the removal of the nesting Derra clamp. A long 22 g needle is placed transthoracic into the outflow graft, which allows it to back bleed from the left ventricle. TEE guidance is used to evaluate air within the LV and evacuated through the proximal and distal 22 g needle holes within the graft. The driveline is connected to the controller and the pump begun at the lowest RPM. A 32 French right angle pleural tube is placed on the right, and the mediastinum is drained with 2-22 French Blake drains. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 8 Following closure of wounds, the HVAD final position, covered with Gore-Tex membrane, is seen. A 24Fr Blake chest tube is placed in the mediastinum, and a 32Fr argyle chest tube is placed on the left pleural space. Postoperative LVAD management is per institutional protocols. Operative Techniques in Thoracic and Cardiovascular Surgery 2017 22, 68-77DOI: (10.1053/j.optechstcvs.2017.04.002) Copyright © 2017 Elsevier Inc. Terms and Conditions