Minimally-invasive LVAD Implantation: State of the Art

Hanke, Jasmin S.; Rojas, Sebastián V.; Avşar, M.; Haverich, Axel; Schmitto, Jan D.

doi:10.2174/1573403x1103150514151750

Cited by 75 publications

(59 citation statements)

References 47 publications

(77 reference statements)

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“…Minimally invasive VAD implantation methods will hopefully further benefit the overall outcome of patients, but structured investigation of these techniques is needed. Although minimally invasive techniques avoid the need for open sternotomy, they also have a greater potential for malposition, the same cumulative incisional length, and still require an open sternotomy if the right ventricle fails . New technological breakthroughs are expected in the future (e.g.…”

Section: Management Strategies For Patients With Advanced Heart Failurementioning

confidence: 99%

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

Crespo-Leiro

Metra

Lund

et al. 2018

European J of Heart Fail

657

605

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This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.

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Section: Management Strategies For Patients With Advanced Heart Failurementioning

confidence: 99%

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

Crespo-Leiro

Metra

Lund

et al. 2018

European J of Heart Fail

657

605

View full text Add to dashboard Cite

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“…The predetermined point of these effects in LVAD patients is the entry of the inflow cannula into the myocardium and the angle between physiological blood flow and the inflow cannula. Despite the many improvements over the last decades, thrombus formation is still one of the Achilles' heels of LVAD therapy (6)(7)(8). The CE mark study of the HM3 showed no thrombus formation in the first follow ups of the study cohort but longer follow up investigations need to be made in order to fully rule out thrombus formation in the new device (9).…”

Section: Discussionmentioning

confidence: 99%

“…Over the last two decades blood pumps have experienced multiple technical developments such as the creation of artificial pulses or substantial miniaturization and the possibility of minimallyinvasive implantation (4,5). Yet, bleeding complications such as thrombosis are still major disadvantages of LVAD therapy (6)(7)(8).…”

mentioning

confidence: 99%

In Vitro Evaluation of Inflow Cannula Fixation Techniques in Left Ventricular Assist Device Surgery

et al. 2016

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The therapy of terminal heart failure with left ventricular assist devices has become a standard in cardiac surgery. Yet the surgical implantation technique is not standardized and differs from center to center. Complications associated with left ventricular assist device (LVAD) inflow cannula placement are thrombosis, suction events, and flow disturbances. Within this in vitro study we aimed to investigate if the fixation technique of the sewing ring has an impact on the position of the inflow cannula. For this in vitro study the HeartMate III LVAD (Thoratec Corporation, Pleasanton, CA, USA) was used. In five sessions, two approaches were considered for coring of the ventricle for LVAD inflow cannula insertion: "sew-then-core" and "core-then-sew." In the "sew-then-core" technique, the sewing cuff is first affixed to the heart, usually with 8-16 interrupted pledgeted mattress sutures. Subsequently, a cylindrical knife is used to resect a cylindrical core of myocardium to permit cannula insertion. In the "core-then-sew" technique, the sequence is reversed such that the knife is used before the suture ring is affixed. When the "sew-then-core" technique is used, the mattress sutures may be placed with full-thickness bites that penetrate the endocardium (i.e., transmural stitching) or partial-thickness bites that do not penetrate the endocardium (i.e., epicardial stitching). When the "core-then-sew" technique is used, the suture is passed fully into the ventricular lumen and fed back through the cored hole, at which point the needle may be reinserted into the freshly cored myocardium such that it exits the epicardium (i.e., transmural stitching with back stitch) or not (i.e., transmural stitching without back stitch). These four different sewing ring fixation suturing techniques were tested by experienced surgeons to affix the sewing ring: transmural stitching, epicardial stitching, transmural stitching with back stitch, and transmural stitching without back stitch. The sewing ring was sewed onto a silicone dummy designed to simulate the left ventricle with standard 2-0 Ethibond sutures (Ethicon, Somerville, NY, USA). Afterward, the dummies were measured and documented via photography. In addition, porcine hearts were used to simulate the suturing techniques in a physiological setting. The setting of the inflow cannula is substantially influenced by the fixation method of the sewing ring. Epicardial stitching showed the best results with stable cannula fixation, minimal gap around the cannula and no contact between the sutures and sewing ring with blood. The method of transmural stitching without back stitch showed the worst results by creating the biggest epithelial gap between inflow cannula and tissue as well as proving the biggest surface for blood contact between sewing ring and sutures. In general, both "sew-then-core" techniques resulted in a greater degree of apposition between the cuff and epicardial tissue. Within the study we revealed that the surgical fixation of the sewing ring has a significant impact o...

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“…When the LVAD implantation has involved both a left thoracotomy and a limited proximal sternotomy instead of a right thoracotomy for anastomosis of the outflow tract to the ascending aorta (9), it is important to ascertain the position of the distal outflow tract in relation to the sternum as lateral placement of the anastomosis through this approach is more difficult.…”

Section: Caveatsmentioning

confidence: 99%

Pre-transplant ventricular assist device explant

Khoshbin¹,

Schueler²

2018

Ann. Cardiothorac. Surg.

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Explantation of a left ventricular assist device (LVAD) may be challenging even in the most experienced hands. We aim to describe the technique for explantation of an LVAD together with the heart as applicable to all contemporary implantable mechanical assist devices. In order to ensure safe explantation, particular care must be taken at three distinct stages: at the time of LVAD implantation, at pre-transplant assessment and at the time of heart transplantation. The preparation for a safe explantation at LVAD implantation includes positioning the driveline and the outflow graft away from the back of the sternum to ensure protection from injury during re-entry into the chest. At transplant assessment, essential investigations include computed tomography (CT) of the chest and ultrasound imaging of femoral vessels. At the time of heart transplantation, the site of peripheral access should be prepared and vessels exposed in case of a need for emergency bypass. We advise careful dissection starting from the lower aspect of the under surface of the sternum, moving as proximally as possible before attempting to use the oscillating saw. Much of the dissection of the heart is done off-pump. Cardiopulmonary bypass may be established either through peripheral vessels or the outflow graft in an emergency. Central direct cannulation is then established. After the heart and major vessels are isolated, explantation of the heart may begin either en-bloc or after splitting the ventricles in a sagittal plane. The basal regions of both ventricles and both atria are removed, leaving generous cuffs for anastomosis of the left atrium, pulmonary artery, aorta, inferior and superior vena cava (SVC). The apex of the heart is then removed with the device taking care not to injure the phrenic nerve.

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Minimally-invasive LVAD Implantation: State of the Art

Cited by 75 publications

References 47 publications

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

In Vitro Evaluation of Inflow Cannula Fixation Techniques in Left Ventricular Assist Device Surgery

Pre-transplant ventricular assist device explant

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