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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Durable mechanical circulatory support (MCS) systems are established therapy option in patients with end-stage heart failure, with increasing importance during the last years due to donor organ shortage. Left ventricular assist devices (LVADs) are traditionally implanted through median sternotomy (MS). However, improvement in the pump designs during the last years led to evolvement of new surgical approaches that aim to reduce the invasiveness of the procedure. Numerous reports and studies have shown the viability and possible advantages of less-invasive approach compared to the sternotomy approach. The less invasive implant strategies for LVADs, while vague in definition, are characterized by minimizing surgical trauma and if possible, cardio-pulmonary bypass related complications. Usually it involves minimizing or completely avoiding sternal trauma, avoiding heart luxation while simultaneously leaving the major part of pericardium intact. There is no consensus between the centers regarding the ideal approach for LVAD implantation. Some centers, like our center, perform by default VAD implantation using less invasive approach in almost all patients and some centers use only sternotomy approach. The aim of this review article is to shed light on the currently available less invasive options of LVAD implantation, with particular focus on the centrifugal pumps, and their possible advantages compared to traditional sternotomy approach.

From the MRC Group for the Study of the Cerebral Circulation, Institute of Neurological Sciences, Glasgow S U MM AR RY By using measurements of cerebral blood flow and internal carotid artery pressure it is possible to select patients in whom carotid ligation can be performed with a very low risk of postoperative cerebral ischaemia. A study has been carried out in 100 patients comparing this method with clinical predictions of the type used in aneurysm surgery based on age of the patient, arterial hypertension, time from latest subarachnoid haemorrhage, and neurological status on a modified Botterell scale. These clinical factors were found to be of little value in predicting which patients would and would not develop cerebral ischaemia after carotid occlusion.

Angiographic assessment of collateral circulation to the brain at the circle of Willis was compared with measurements of cerebral blood flow (CBF) and internal carotid artery pressure during temporary carotid clamping in the prediction of tolerance of unilateral carotid ligation as treatment for intracranial carotid aneurysms in 92 patients. From CBF studies it was predicted that a substantial number of patients (27%) would suffer severe cerebral ischemia if carotid ligation were carried out. No single angiographic feature provided this predictive information. Bilateral fetal type of posterior communication arteries were associated with significantly lower carotid artery back pressure on temporary carotid occlusion, and unilateral absence of posterior communicating arteries was related to llower CBF, but neither feature was associated with a signifiant reduction in the rate of successful carotid ligation. We believe that preliminary percutaneous digital corotid compression with electroencephalographic monitoring, followed by intraoperative measurement of the change in regional CBF and internal carotid artery pressure during temporary carotid clamping provides a safe method of selecting patients for carotid ligation. Carotid angiography with or without contralateral carotid compression is of little value in this respect.

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