OBJECTIVE: The purpose of this video is to illustrate our technique for robotically assisted minimally invasive left ventricular assist device (LVAD) insertion.METHODS: Intra-operative images and video were obtained and compiled which demonstrate this technique. The patient is prepared for surgery as for standard minimally invasive LVAD insertion. A double-lumen endotracheal tube and transesophageal echo are employed. The patient is prepared in the supine position with arms tucked. A small left thoracotomy is created and the left ventricular apex is exposed. The LVAD sewing ring is anastomosed to the LV apex at a location identified with palpation and echocardiography. Simultaneously, a right mini-thoracotomy is created and robotic ports are placed. After femoral cannulation and initiation of cardiopulmonary bypass, a core of apical myocardium is excised and the LVAD is inserted into the apex through the left thoracotomy. The driveline is tunneled and brought out in a location in the left upper quadrant. The outflow graft is then passed from the left thoracotomy to the right under direct visualization and entirely within the pericardium. A minimally invasive side biting clamp is used to partially occlude the ascending aorta. The outflow graft is trimmed and beveled, and an aortotomy is created. Using robotic assistance, the outflow graft anastomosis is then created. The outflow graft is de-aired. The clamp is removed and LVAD flows are initiated. Cardiopulmonary bypass is then weaned as LVAD flows are decreased. Cardiopulmonary bypass is terminated. Hemostasis is assured, chest tubes are placed, and all incisions are closed. RESULTS: Robotically assisted minimally invasive LVAD insertion can be safely performed with a successful outcome. In the case illustrated here, the patient recovered well and was discharged from the hospital on post-operative day 10 in good condition despite undergoing LVAD insertion in the setting of cardiogenic shock. CONCLUSIONS: Robotic assistance can be useful for minimally invasive LVAD insertion. Employing robotics for the outflow graft anastomosis allows complete avoidance of sternotomy and facile suturing through a right mini-thoracotomy. The outflow graft is well protected during re-entry for heart transplantation. In the future, totally endoscopic LVAD insertion may be feasible.
