Our experience has demonstrated benefits of off pump minimally invasive left ventricular assist device (LVAD) implantation. We describe the anesthetic management for this innovative technique addressing technique-specific issues such as arrhythmia management, hemostasis, right heart failure and postoperative pain control. In this single-center case series, we analyzed data from five consecutive patients (one surgeon and one anesthesiologist) who underwent implantation of a fully magnetically levitated LVAD using complete sternal-sparing approach without cardiopulmonary bypass (CPB). Anesthetic concerns were identified which would compromise the potential outcomes of this innovative technique. Five patients were implanted off pump via bilateral thoracotomies (80% male, median age 59 yrs). Three patients required preoperative impella placement and four required preoperative VA-ECMO. Minimally invasive cardiac surgery usually requires one lung ventilation to optimize exposure; however, 100% of these patients were managed with a single lumen endotracheal tube. Arrhythmia protocols included magnesium infusion, amiodarone bolus/infusion and potassium administration; successfully eliminating the occurrence of any fatal arrhythmias or defibrillation during placement of the inflow ring. Rapid ventricular pacing and steep Trendelenburg position during coring of the left ventricular apex minimized blood loss. Right ventricular failure was successfully averted in all patients using vasoactive agents, phosphodiesterase 3 inhibitors, aerosolized synthetic prostacyclin agonists and adherence to strict hemodynamic parameters post LVAD insertion. Use of peripheral nerve blocks (left serratus anterior plane block and right subpectoral interfascial plane block) decreased postoperative pain, minimized opioid use and allowed for faster extubation (median 20.75 hrs) and discharge from intensive care unit (median 6 days). 100% of these patients survived to discharge. We have developed a comprehensive protocol to address multiple anesthetic concerns involved with the challenging off pump complete sternal-sparing technique LVAD implantation, achieving 100% survival to discharge in this initial cohort. Further studies are needed to corroborate this single-center experience.