Less invasive left ventricular assist device implantation may reduce right ventricular failure

Abstract

OBJECTIVES Right ventricular (RV) failure after left ventricular assist device (LVAD) implantation continues to be a morbid complication. In this study, we hypothesized that a less invasive approach to implantation would preserve RV function relative to a conventional sternotomy (CS) approach. METHODS All patients (2013–2017) who underwent LVAD implantation were reviewed. Patients were stratified by surgical approach: less invasive left thoracotomy with hemi-sternotomy (LTHS) and CS. The primary outcome was severe RV failure. RESULTS Eighty-three patients (LTHS: 37, CS: 46) were identified. The median Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score was significantly worse in the LTHS compared to the CS cohort, and there was a trend towards higher RV failure scores and HeartMate II mortality scores. Preoperative RV dysfunction, in pulmonary artery pulsatility index and RV stroke work index were similar between the 2 groups. Though operative time did not significantly differ between the 2 groups, cardiopulmonary bypass time was significantly shorter in the LTHS group (61 vs 95 min, P < 0.001). The incidence of postoperative severe RV failure was significantly reduced in the LTHS group (16% vs 39%, P = 0.030), along with the need for temporary right ventricular assist device (3% vs 26%, P = 0.005). Improvement in RV function, along with a change in pulmonary artery pulsatility index, was significantly greater in the LTHS cohort. There was a trend towards improved Kaplan–Meier 1-year survival in the LTHS cohort (91% vs 56%, P = 0.056). CONCLUSIONS In this cohort, less invasive LVAD implantation appears to be associated with reduced postoperative RV failure, and equivalent or improved survival compared to conventional LVAD implantation.

Sex differences in outcomes following less-invasive left ventricular assist device implantation

“…In particular, the impact of surgical approaches on LVAD outcomes in women is still unknown. It has been demonstrated that less-invasive techniques can significantly modify LVAD outcomes (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32). However, since women are often under-represented in clinical studies, little is known about sex differences in outcomes following less-invasive LVAD implantation.…”

“…With the device miniaturization, a lateral thoracotomy for LVAD implantation (20) has gained relevance (2). Avoiding sternotomy and minimizing surgical trauma leads to reduced postoperative bleeding (21,22), less transfusions (23), lower incidence of RHF (21,(24)(25)(26), shorter hospital stay (21)(22)(23)(24)(25)(27)(28)(29)(30) and lower costs (31,32).…”

Outcomes with temporary mechanical circulatory support before minimally invasive centrifugal left ventricular assist device

“…It has been postulated that leaving the heart in its natural position, avoiding RV compression, and leaving the pericardium intact reduce post‐LVAD RV distention and failure 16 . We have previously shown that the LTHS approach improves outcomes in patients with RV failure 17 …”

A Minimally Invasive Approach to Left Ventricular Assist Device Insertion Facilitates Subsequent Explant

“…5,7,8 Less invasive approaches may have a number of benefits at the time of LVAD insertion, including lower rates of right ventricular failure. 5,8,9 However, the influence of a less invasive approach to LVAD insertion on subsequent cardiovascular reoperations has not been well studied. We present the case of a patient who underwent LVAD implantation in the setting of cardiogenic shock; his LV function subsequently improved and he underwent VAD explant without the use of blood products or inotropic support.…”