Heart transplantation is the most effective method of enhancing quality of life and survival in end-stage heart failure (HF) patients. Unfortunately, the Achilles’ heel of this excellent treatment is the severe shortage of donor organs. Consequent to this mismatch between supply and demand, of particular importance has become the application of the ventricular assist devices (VADs) [1–9]. The field of circulatory support has matured dramatically in recent years, thanks to the advent of smaller, rotary pumps and new surgical and anesthetic solutions. These improvements have changed the face of advanced heart failure care [10, 11]. New management strategies associated to new pump technology over the years modified the mechanical circulatory support (MCS) candidate selection and risk stratification. In the next future, familiarity with newer pump devices and patient management strategies should accelerate the timing and improve the referral for MCS evaluation.

Therefore, MCS device use in severe heart failure, opened to discussion decades ago, is now well established, either for temporary support such as bridge to transplantation or destination therapy [4]. Consequently, left ventricular assist devices (LVADs) have become nowadays the principle alternative treatment for end-stage heart failure unresponsive to optimal medical therapy.

The typical VAD candidate is commonly very compromised and may not have sufficient resources to tolerate major surgical insults and trauma. Therefore, device implantation through smaller, less traumatic incisions is a desirable goal. The median sternotomy decreases lung volumes and reduces thoracic motion with significant decrease in functional residual capacity and total lung capacity months later [12]. Minimally invasive cardiac surgery via mini-thoracotomy was devised to reduce morbidity because of potentially less inflammatory response and reduce transfusion requirements and scarring, with consequent rapid rehabilitation to normal life activity [13]. Additionally, avoiding the cardiopulmonary circulatory support (CPB) even for short period of time might reduce the release of inflammatory cytokines and their consequences, as most CPB-related damage happens within the first few minutes [14, 15].

Different approaches are described for implantation of VADs, including off-pump [16], subcostal [11], or mini upper sternotomy implantation [17]. In this chapter, we describe the minimally invasive techniques used for the implantation of an LVAD that involve three distinct professional figures within the operating room: the surgeon, the anesthesiologist, and the perfusion technician [18–24].

Off-pump implantation: Avoiding CPB reduces the release of inflammatory cascade and its consequences [8, 11, 13]. The reduced heparin dose necessary for the off-pump implantation favors a reduction in intraoperative and postoperative bleeding and thus a decreased blood unit transfusion and immunization, particularly important for patient’s bridge to transplantation.

Minimally invasive surgical approach: There is a growing trend toward the use of non-sternotomy incisions and/or mini-thoracotomy in all fields of cardiac surgery [14, 15]. Although full-median sternotomy provides the best access to the heart and the adjacent structures, it can be replaced by smaller incisions in most of the cases. The choice for minimally invasive approaches was powered by the possibility of a preserved good exposure of the great vessels (through upper mini-sternotomy or II intercostal space mini-thoracotomy) and the minimal displacement of the heart for left ventricle apex exposure (through mini-thoracotomy), with decreased rate of arrhythmias and hemodynamic instability related to the heart manipulation, mandatory when in full sternotomy. Additionally, less-extensive mediastinal dissection reduces the risk and the degree of postoperative bleeding.

Paravertebral analgesia and mild general anesthesia: The hemodynamic fragility of these patients is well reported, and renal insufficiency, pulmonary hypertension, as well as COPD stand out as risk factors. Furthermore, when a prolonged mechanical ventilation is required, the cerebral perfusion and oxygenation are compromised [12, 25–33]. In order to improve the patient management, paravertebral analgesia has been suggested in association to a mild general anesthesia. Many authors [12, 25–33] have confirmed the advantages and efficacy of continuous paravertebral block (PVB) for analgesic treatment of thoracotomies when compared to epidural analgesia with lower complication rate (pulmonary, renal, gastrointestinal, and hemodynamic). Additionally, PVB provides safe, effective analgesia, diminishes the early reduction of postoperative pulmonary function, and restores respiratory mechanics more rapidly, with consequent facilitated extubation. The local anesthetics migrate from this injection site, both caudally and rostrally, and produce unilateral somatic and sympathetic nerve blockade. The risk of wrong positioning the PVB catheter in the epidural or spinal space with subsequent risk of epidural hematoma is considered low when the preoperative coagulation tests are normal and when lower doses of heparin are administrated. Same low risk was considered when PVB catheter is removed 48 h after surgery. This analgesia does not influence the hemodynamic stability and permits a mild general anesthesia approach.

From December 2008 to January 2016, 96 patients with HF refractory to medical therapy were implanted with the last-generation LVAD: 53 % with Jarvik 2000 (Jarvik 2000 (Jarvik Heart Inc., New York, NY)) and 44 % with HeartWare HVAD (HeartWare Inc., Framingham, MA). Three additional patients (3 %) received HeartMate II (Thoratec, Pleasanton, California) (two patients) and HeartMate III VAD (Thoratec Corp, Pleasanton, CA) (one patient). Mainly male patients (83.1 %) with dilated cardiomyopathy prevalent (58.5 %), followed by ischemic (33.7 %) and fewer different cardiomyopathies such as peripartum, myocarditis, amyloidosis, and arrhythmogenic, came to our attention in very compromised hemodynamic conditions (INTERMACS I and II 92.3 %). Initially, the policy of our center was the implantation of Jarvik 2000 as destination therapy (DT) and HeartWare HVAD as bridge to transplantation (BTT). Recently, we focus on the expected duration of assistance (short or long time), right ventricle performance, pulmonary artery pressure, BSA, technical considerations, pathology, residency, behavior of the coagulation system, and INTERMACS class.

Hereunder are described the different procedures adopted for the implantation of different models of VAD. Afterward, a step-by-step description of the evolution of minimally invasive implantation techniques, for each model of VAD used at the Cardiac Surgery Unit of Padua, is described, with also a discussion of the tricks and traps of the surgical and anesthetic aspect for each evolution of the minimally invasive procedures.

In the operating room, after light sedation (IV 1 mg midazolam), thoracic paravertebral block (PVB) is performed in the awake patient placed in lateral or sitting position by skillful anesthesiologist. After local anesthetic infiltration of the skin and muscular plane (5 ml lidocaine 2 %), a Tuohy 17-gauge needle is inserted at level of T4-T5, 3 cm on the left side of the spinous process of the T4 dorsalis vertebra. Identification of the paravertebral space is done by loss-of-resistance technique, without ultrasound or nerve stimulator, first identifying T4 transversus process with a recently reviewed technique [33]. According to the surgical approach (mono- or bithoracotomic), asymmetric mono- and/or bilateral PVB analgesia is performed. The left block is set by a catheter inserted 3 cm on the left side of the spinous process of T4 dorsalis vertebra, between fourth and fifth inter-transverse process, and the right PVB is established by a catheter inserted 3 cm on the right of the spinous process of T2 dorsalis vertebra, between third and fourth inter-transverse process.

When paravertebral space is reached, an epidural catheter (19 gauge) is inserted and left at 2 cm beyond the tip of the needle. A subcutaneous tunnel is made for avoiding accidental catheter removal. A cumulative dose of 20 ml of 0.5 % ropivacaine (100 mg) is done for intraoperative analgesia (10 ml at left mini-thoracotomy closure). Induction of general anesthesia is performed with doses of sodium thiopental (4 mg/kg), fentanyl (200 mcg total dose), and rocuronium (0.6 mg/kg). A single lumen tube (monolateral approach) or a bi-lumen endotracheal tube (bilateral approach) is inserted for endotracheal intubation and mechanical ventilation performed with a protective strategy (tidal volume 8 ml/kg, respiratory rate 10 b/min, PEEP: 4 cmH2O). Anesthesia is maintained by propofol (3–5 mg/kg/h) and remifentanil infusions (0.05–0.1 mcg/kg/min). At the end of the surgical procedure, remifentanil and propofol infusion are suspended, and extubation is performed if possible in short time in OR, in order to guarantee afterload reduction of the right ventricle. The patients are transferred to the ICU. Postoperative pain control is assured by 0.2 % ropivacaine continuous infusion at speed of 5 ml/h by paravertebral route, intravenous continuous infusion (elastomeric device) at 3 mcg/h of sufentanil, and intravenous analgesics upon patient request. PVB catheter is maintained for 48 hrs and afterward removed.

As premedication, flunitrazepam, 2 mg, is administered orally 90 mins before surgery. On arrival in the operating room, a large-bore peripheral venous catheter and a radial artery catheter are inserted. After baseline monitoring, intravenous (IV) anesthesia is induced, following preoxygenation, over a period of 10 mins with thiopental, 1.5 mg/kg; fentanyl, 5 mcg/kg; and rocuronium, 0.6 mg/kg. Endotracheal intubation is performed 5 mins after administration of rocuronium, and controlled ventilation with oxygen/air (FIO₂ = 0.6) is instituted to normocapnia (end-tidal PCO₂ 35–40 mmHg). Endotracheal intubation is performed with single or double lumen tube, with possibility to exclude right or left lung when necessary. After induction of anesthesia, a central venous catheter is inserted in the right internal jugular vein. The central venous catheter (CVC) is positioned on the left jugular vein for not cluttering the pedestal implant procedure (in case of Jarvik 2000 implantation). In this phase, anesthesia is maintained with continuous inhalation of sevoflurane (0.9 %) and sufentanil (0.1 mcg/kg/h). Before thoracotomy and mini-sternotomy, IV continuous infusion of propofol at a rate of 4–6 mg/kg/h is started. During and after the incisions, both groups are supplemented with intermittent boluses (5 mcg/kg) of fentanyl (up to a total maintenance dose of 30 mcg/kg) received prophylactically to blunt brief but intense periods of pain and autonomic stimulation (sternal splitting and spread, aortic mobilization, clamping and de-clamping, and sternal thoracotomy closure). Each patient receives 0.025 mg/kg of pancuronium every hour for muscle relaxation and mechanical ventilation during surgery. Propofol infusion is stopped at the end of surgery, and extubation is performed if possible in the operating room (OR). Postoperative pain control is assured by intravenous continuous infusion (elastomeric device) at 3 mcg/h of sufentanil at the first 48 postoperative hours and intravenous analgesics upon patient request.

In both modalities, anesthesia is monitored by the bispectral index of the EEG (BIS) [BIS® monitor; Aspect MS, Newton, MA-USA]. A Swan-Ganz catheter and a transesophageal echocardiography probe are inserted for monitoring right and left ventricular function and LVAD inflow cannula orientation. The visual analog scale (VAS) is used to assess the quality of analgesia, and data are collected at 1, 6, 24, and 48 h postoperatively [18–24].

Initially the routine technique was the left thoracotomy (17 pts.; 17.8 %). It currently is used only in cases of reoperation or impossibility to approach the ascending aorta. Subsequently, we experienced full sternotomy for only 13 cases (13.5 %). Almost immediately, the technique evolved toward a less invasive approach with the combination of the anterior left mini-thoracotomy (LMT) to high mini-sternotomy (28 pts.; 29.2 %). Nowadays, the approach of choice is the association of anterior LMT in fifth intercostal space with anterior right mini-thoracotomy (RMT) in II intercostal space (32 pts.; 33.4 %) or left axillary artery (6 pts.; 6.1 %).

For the HVAD, the technique is simple and rapid: the driveline is tunneled subcutaneously from LMT to the exit point at left lower abdominal quadrant and thereafter re-tunneled to exit its tip contralaterally at right lower abdominal quadrant.

For the Jarvik 2000, the driveline positioning is more complex and time-consuming: the power cable is tunneled through the LMT underneath the pericardium following the profile, by using a blunt-tip instrument, and stretched to the upper mini-sternotomy. The pedestal is then secured to the parietal bone behind and slightly above, indifferently the right or left ear. A C-shaped incision is performed around the ear, and a full-thickness flap is raised down to the periosteum. Recently we changed the incision shape versus a straight line incision, to preserve the vascularization of the flap. The periosteum is elevated beneath the skin flap, and a template is used to define the position of the bone screws. Any skull irregularity is burred-off to give a flat surface. The three-pin connector is tunneled from the jugular space, through the neck, to the behind-the-ear connector position, and then inserted in the titanium pedestal. To convey the three-pin connector and power cable to the skull pedestal site, the incision is made on the neck, almost 2 cm under the basis of the ear. The tunneling is achieved by inserting the three-pin connector within the end of an intercostal drain. The drain is withdrawn out of the chest and through the neck to the scalp. The three-pin connector is then inserted through the titanium pedestal. This is then implanted firmly onto the external table by using 7 or 8 mm bone screws. The postauricular skin flap is repositioned with the percutaneous pedestal through the punched-out defect. The scalp and skin incisions are then closed securely. The external power cable is attached to the skull pedestal, and with the Jarvik 2000 LVAD outside the ventricle, the power is switched on to test the device in a basket filled with saline solution.

Fourth step: The VAD sewing ring is secured by using interrupted 2–0 polypropylene-pledgeted sutures and sealing the suture line applying BioGlue (CryoLife, Kennesaw, GA). Once 5000 UI of heparin is administered, VAD inflow cannula is off-pump inserted into LV through the apex. The correct housing position of the cannula is echocardiographically monitored and then tightened the sewing ring (◘ Fig. 24.2).