Minimally Invasive Implantation of HeartWare Assist Device and Simultaneous Tricuspid Valve Reconstruction Through Partial Upper Sternotomy

Abstract

Left ventricular assist device (LVAD) implantation is a well-established therapy to support patients with end-stage heart failure. However, the operative procedure is associated with severe trauma. Third generation LVADs like the HeartWare assist device (HeartWare, Inc., Framingham, MA, USA) are characterized by enhanced technology despite smaller size. These devices offer new minimally invasive surgical options. Tricuspid regurgitation requiring valve repair is frequent in patients with the need for mechanical circulatory support as it is strongly associated with ischemic and nonischemic cardiomyopathy. We report on HeartWare LVAD implantation and simultaneous tricuspid valve reconstruction through minimally invasive access by partial upper sternotomy to the fifth left intercostal space. Four male patients (mean age 51.72 ± 11.95 years) suffering from chronic heart failure due to dilative (three patients) and ischemic (one patient) cardiomyopathy and also exhibiting concomitant tricuspid valve insufficiency due to annular dilation underwent VAD implantation and tricuspid valve annuloplasty. Extracorporeal circulation was established via the ascending aorta, superior vena cava, and right atrium. In all four cases the LVAD implantation and tricuspid valve repair via partial median sternotomy was successful. During the operative procedure, no conversion to full sternotomy was necessary. One patient needed postoperative re-exploration because of pericardial effusion. No postoperative focal neurologic injury was observed. New generation VADs are advantageous because of the possibility of minimally invasive implantation procedure which can therefore minimize surgical trauma. Concomitant tricuspid valve reconstruction can also be performed simultaneously through partial upper sternotomy. Nevertheless, minimally invasive LVAD implantation is a challenging operative technique.

Minimally Invasive Aortic Root Replacement with Valved Conduits through Partial Upper Sternotomy

“…Furthermore, we expanded the indication for this minimally invasive access and increasingly use it in patients with the need for left ventricular assist device (LVAD) support or even combined procedures such as LVAD implantation and tricuspid valve repair. 12 Bentall and de Bono developed the composite aortic valve and root replacement with coronary artery reimplantation in 1968, and during the following years, the technique was modified. [17][18][19][20] Later on, valve-sparing operations 21,22 and implantation of valved conduits were used for ARR.…”

“…Within the last years, the use of minimally invasive surgical access techniques such as partial upper sternotomy (PUS) increased, as its advantages could be demonstrated in numerous clinical trials. [1][2][3][4][5][6][7][8][9][10][11][12] Until now, minimally invasive surgical access is not routinely used in patients with the need for aortic root replacement (ARR), and full median sternotomy remains the standard operative access.…”

Minimally invasive ventricular assist device implantation

“…Never the less, Hillebrand et al reported 4 cases of less invasive LVAD-Implantation and concomitant TVR using Cosgrove-Edwards partial flexible annuloplasty ring for tricuspid valve regurgitation through upper hemi-sternotomy under complete CPB. The survival rate remained 100% for these patients (29). Further, Schaefer et al reported a case of successful less invasive HeartWare HVAD Implantation and simultaneous transapical transcatheter aortic valve replacement using a JenaValve (JenaValve Technologies Inc., Munich, DE) in a patient with ischemic cardiomyopathy and aortic valve regurgitation through right anterior and left anterior thoracotomies.…”

Artificial Organs 2017: A Year in Review

“…Hillebrand et al of the University Hospital of the Westfaelische Wilhelms‐University Muenster, Muenster, Germany reported on minimally invasive implantation of the HeartWare assist device and simultaneous tricuspid valve reconstruction through partial upper sternotomy. Four male patients underwent this procedure.…”