Step 1. Combination of Minimally Invasive Incisions
◆ An intrapericardial implantation of a left ventricular assist device in the younger patient could be performed through a combination of an upper partial sternotomy and a left anterolateral thoracotomy. This procedure possibly reduces intrapericardial adhesion and facilitates the heart transplantation.
Figure 1.7 By the clamshell approach, the sternum is transversally divided at the level between the 3rd and 5th intercostal space. The upper part of the thorax is opened like a clamshell with retractors. Sternum wires and PDS pericostal sutures are used to close and stabilize the thorax at the end of the procedure.
Step 2. Other Incisions
◆ Other incisions are used occasionally for extended exposure of the great vessels. The clamshell approach (Fig. 1.7) enables access to the hilum of each lung and is an option for bilateral lung transplantation or heart-lung transplantation. This approach provides an excellent exposure of the heart and descending aorta, and may be used for select cases that require extended aortic surgery.