How to do it: thoracoscopic left ventricular assist device implantation using robot assistance.

Left ventricular assist devices (LVADs) improve quality of life and reduce mortality of patients with heart failure.1 Although LVAD outcomes improve, unavoidable consequences of implantation remain. Given the likeliness of prior cardiac surgery, LVAD candidates for a “bridge to transplant” raise concerns regarding the number of redo sternotomies. Each sternotomy places patients at greater risk for mortality, morbidity, and resource use (eg, blood transfusions and length of stay).2 These increased risks are attributed to patients' heart failure associated with sternum-adherent dilated right ventricles (RVs).3 Direct cardiac dissection of adhesions via sternotomy can be poorly tolerated and trigger postoperative RV failure by prolonged cardiopulmonary bypass (CPB) time, bleeding, excessive transfusions, and inflammation. An alternative to redo sternotomy is a robotic endoscopic approach via thoracic chest ports. This indirect approach to the retrosternal space improves adhesion visualization, allowing more precise dissection. Reports of robotic use for redo or high-risk cases led us to assess robotic utility to reduce the invasiveness and morbidity in patients undergoing LVAD implantation.