Off-pump and ECMO support LVAD implantation have been developed to reduce the overall invasiveness of LVAD implantation. Especially multimorbid patients in terminal heart failure with chronically injured end organs could benefit from these approaches. Despite the obvious advantages, the main concerns with off-pump and ECMO support LVAD implantation are the inability to visualize the LV cavity during surgery to rule out LV thrombus and obstructing trabeculations. Missing LV thrombus formation could lead to devastating thrombus dislodgement or suction into the LVAD, and obstructing trabeculations can limit LVAD flow and LV unloading.

While off-pump LVAD implantation developed as a discrete procedure, ECMO support LVAD implantation was first described in bridge-to-decision patients [4, 5]. In this distinct population, switching to cardiopulmonary bypass can thereby be avoided [4, 5]. Combining the ECMO circuit with a cell saver system also allows for expeditious blood re-transfusion; the overall procedure is very much straightforward, and surgeons do not have to leave the comfort zone provided by the ECMO as a hemodynamic safety net. Results with this approach have to be assessed in light of a high percentage of INTERMACS I patients operated with this approach. Technical success rates of 100% without conversions to cardiopulmonary bypass have been reported in both major series [4, 5]. In-hospital survival of 90–95% and 1 year survival of 86% underline the safety of the procedure [4, 5]. Of note, no thrombus dislodgements or embolization has been reported and the observed stroke rates compare to standard LVAD implantation with cardiopulmonary bypass [4, 5]. So far, no reports on elective ECMO LVAD implantation have been published. Therefore, it can only be speculated that exchanging cardiopulmonary bypass by ECMO might be beneficial. Some evidence supporting this assumption might be derived from lung transplantation [10].

Off-pump LVAD implantation developed as a distinct surgical approach, and many of us have used this approach for experimental VAD implantation in the animal lab [6–9]. In contrast to ECMO support LVAD implantation, off-pump LVA implantation requires the surgeon and the entire surgical team to leave the comfort zone provided by cardiopulmonary bypass and close interactions between all team members become necessary, similar to off-pump CABG [6–9]. However, as soon as the entire team gets comfortable with this approach, it is a perfectly standardized, reproducible, teachable, and safe procedure that truly minimizes the insult of LVAD implantation. Besides technical success and survival rates, off-pump LVAD implantation especially has to be assessed with regard to thromboembolic complications. The three major series on off-pump LVAD implantation report technical success rates of 100% without any conversions to cardiopulmonary bypass [6–9]. Of note, two publications only address HeartWare HVAD off-pump implantation, which is probably best explained by the fact that the HVAD apical sewing ring and coring device allow for a staged procedure and maximal intraoperative hemodynamic stability [5, 7]. Survival rate with off-pump LVAD implantation are excellent and reach up to 90% at 6 months and 85% at 1 year [6–9]. So far no long-term survival rates have been published [6–9]. Importantly, off-pump LVAD implantation was not associated with any intraoperative thromboembolic events in all published series and the overall thromboembolic event rates compare to those reported after standard LVAD implantation [6–9].