Left Lateral Thoracotomy for Centrifugal Continuous-Flow Left Ventricular Assist Device Placement: An Analysis from the Mechanical Circulatory Support Research Network

Abstract

Continuous-flow left ventricular assist devices (CF-LVADs) have revolutionized the management of patients with advanced heart failure. Alternative implant strategies are increasingly used for device placement. We reviewed our experience from the Mechanical Circulatory Support Research Network registry with the HeartWare centrifugal CF-LVAD (HVAD). From May 2004 to August 2015, 1,150 patients underwent primary CF-LVAD implantation at our institutions. Within this group, a total of 283 patients (25%) were implanted with the HVAD. A minimally invasive left lateral thoracotomy (MILT) implant strategy was used in 53 patients (20%), of which 22 (42%) were implanted off-pump. Median age at implant was 59 years and 183 patients (65%) were implanted as bridge-to-transplantation. Follow-up was 100% complete for a total of 302 patient-years of support. In-hospital mortality was 4.9% (14 patients), and was comparable between the conventional sternotomy (CS) and MILT cohorts (p = 0.15). Patients in the MILT cohort had a shorter median length of stay (p < 0.01) and had a lower incidence of postimplant pump thrombus (p = 0.02). Cumulative survival at the end of follow-up reached 84%, and was comparable between the two groups (p = 0.298). Multivariate analysis identified preoperative bilirubin level as the only independent predictor of survival. Surgical technique had no impact on survival. In this large, multicenter experience, data demonstrate excellent survival and adverse event profiles for patients supported with the HVAD technology, regardless of surgical implant technique. With constant advancements in device technology along with our increasing clinical experience with the newer techniques, minimally invasive LVAD implantation continues to evolve as a valuable alternative to CS in selected patients.

Implantation of a fully magnetically levitated left ventricular assist device using a sternal-sparing surgical technique

“…Patients in the SS cohort were extubated earlier, although there was there was no significant difference in ICU LOS, which is consistent with previous reports. 8 Earlier extubation was facilitated by decreased bleeding and thus decreased post-operative resuscitation requirements, allowing for the preservation of normal respiratory mechanics. 18 A key component of our peri-operative management includes regional nerve blocks as part of a multimodal, opioid-sparing post-operative analgesia protocol.…”

Heart transplantation in patients with ventricular assist devices: Impacts of the implantation technique and support duration

“…As VAD support may affect the outcome after HTx, new therapies are needed to improve the HTx results for these patients. In recent years, minimally invasive implantation techniques without conventional full sternotomy for left VADs (LVADs) have become increasingly popular . By using minimally invasive implantation techniques, the number of thoracic adhesions, which could complicate a future HTx procedure, might be reduced compared to that with conventional techniques …”

Bridge to Transplantation With Long‐Term Mechanical Assist Devices in Adults With Transposition of the Great Arteries

“…A recent analysis of the Mechanical Circulatory Support Research Network showed that a MILT approach was used in approximately 20% of patients receiving HeartWare HVAD systems . A small proportion of patients deemed to be high risk underwent a left thoracotomy with outflow cannula to the descending aorta . Our report is the first in the literature to use this alternative approach in this unique population of congenital heart disease patients suffering from systemic ventricular failure with palliated or congenitally corrected transposition of the great arteries.…”