Ventricular assist devices (VADs) have revolutionized treatment of advanced heart failure. VAD recipients benefit from improved functional status, better quality of life and good survival result. The advancement of post-VADs implant management, improved durability of devices and scarcity of heart donor have made VAD an attractive alternative to heart transplant, with an increasing trend of it being used as destination therapy rather than bridge therapy. The increasing demand for VAD therapy and complexity of patients called for alternative VAD implantation approaches to be addressed. We report a case of HeartWare VAD implantation via left thoracotomy with outflow graft anastomosis to the descending aorta in a patient with previous sternotomy from coronary artery bypass.