Single-Center Experience of Minimally Invasive Left Ventricular Assist Device Implantation

Objectives: Minimally-invasive left ventricular assist device (LVAD) implantation avoids full sternotomy or sternotomy at all and may therefore reduce the surgical risk of subsequent transplantations and right heart failure. We demonstrate our results of minimally-invasive LVAD implantation done via left thoracotomy (LT group) and compare these to LVAD implantations done via full median sternotomy (STX group).

Methods: We retrospectively analyzed data of 70 patients (LT group n = 22, age 52 ± 15 years; STX group n = 48, age 59 ± 11 years), who received a HVAD system (HeartWare^®, Framingham, Massachusetts) between 2010 and 2015. 31.8% (7/22) of the LT group and 56.3% (27/48) of the STX group belonged to INTERMACS level I/II, whereas 68.2% (15/22) of the LT group and 43.7% (21/48) of the STX group were classified as INTERMACS level III/IV. In the LT group, the HVAD pump was implanted via left lateral thoracotomy. In 81.8% (18/22) of the patients, the outflow graft was anastomosed to the ascending aorta via right minithoracotomy (n = 14) or hemisternotomy (n = 4); 18.2% (4/22) of the patients received anastomoses to the descending aorta due to previous cardiac surgery. Cardiopulmonary bypass was introduced percutaneously into the femoral vessels. Due to right heart dysfunction, 40.9% (9/22) of the LT group received concomitant temporary right ventricular support (tRVAD).

Results: The minimally-invasive access was feasible in all patients. The 2-year survival of the LT group (59.1%) was non-significant superior compared with the STX group (47.9%) (p = 0.62). During follow-up 6 patients were transplanted (LT group 2/22, STX group 4/48) and 3 STX patients have been weaned with subsequent LVAD explantation. LVAD-specific infections were less likely in the LT group (p = 0.06). The most common cause of death was multiple organ failure (LT group 3/22, STX group 12/22). Patients receiving minimally-invasive LVAD without tRVAD showed a significant superior survival compared with patients with LVAD/tRVAD implantation (p = 0.022). During the 2-year follow-up, right ventricular failure occurred in 9.1% (2/22) of the LT group compared with 10.4% (5/48) in the STX group (p>0.05).

Conclusion: The minimally-invasive LVAD implantation technique is feasible. This approach is non-inferior compared with full median sternotomy and particularly suitable for bridge-to-transplant patients. Avoidance of right heart failure could not be demonstrated and needs to be discussed in larger patient cohorts.

 

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