Innovation
A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: Early experience

https://doi.org/10.1016/j.healun.2014.05.016Get rights and content

Background

The HeartWare (HeartWare International, Inc. Framingham, MA) ventricular assist device (HVAD) is approved for implantation through a sternotomy with cardiopulmonary bypass. We report on our initial experience with this device implanted off-pump via thoracotomy.

Methods

A total of 26 patients were included in this review. All patients were Interagency Registry for Mechanically Assisted Circulatory Support categories 2 or 3 and underwent implantation of an HVAD as an elective procedure via thoracotomy and mini sternotomy approach. Three-dimensional echocardiography was used to assess the ventricle and was also used to facilitate proper pump positioning. Patients were managed during follow-up using anti-coagulants at a target international normalized ratio 2.0 to 2.5 as well as anti-platelet agents.

Results

Implantation was performed without the use of cardiopulmonary bypass, but 1 patient did require conversion to on-pump surgery. There were no perioperative deaths or right heart failure events. The mean intensive care unit stay was 1.5 days. Transfusions of 1 to 3 units of packed red blood cells were required in 16 patients, whereas 10 patients maintained a stable perioperative hematocrit of at least 30% and did not require transfusion. Survival through 90 days was 100%, and survival through 180 days was 87%.

Conclusions

Our experience was favorable in respect to outcome, safety, and use of blood products. Our technique can be used as an alternative approach for left ventricular assist device implantation using the HVAD.

Section snippets

Patients

After informed consent of the patients, data of 26 patients who underwent implantation of an HVAD System as an LVAD since June 2012 were analyzed in a prospective manner.

Inclusion criteria

The analysis included patients who fulfilled Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) categories 2 and 3 after evaluation and hemodynamic stabilization. The surgery was scheduled as an elective procedure so that informed consent for the procedure could be obtained.

Exclusion criteria

The analysis excluded

Results

Ann off-pump thoracotomy approach was used to perform 26 consecutive HVAD implants from June 2012 to April 2013. The overall number of isolated LVAD procedures at that time was 43. Baseline data for the 26 patients are presented in Table 1. Seven patients had undergone prior cardiac surgery, of whom 4 had undergone prior revascularizations, with mostly patent grafts, and the remaining 3 had undergone mitral valve surgery. All patients fit INTERMACS criteria 2 or 3.

Table 2, Table 3 report the

Discussion

This analysis demonstrates the safety and feasibility of implantation of the HeartWare System as an LVAD by the off-pump thoracotomy approach. Despite the limited viewing field, there are no problems with proper placement of the inflow at the apex. Still, care must be taken to ensure an appropriate size of the thoracotomy to allow rapid insertion of the HVAD into the ventricle. The use of advanced imaging modalities, such as 3D Echo, to visualize possible thrombus and

pump placement is the key

Disclosure statement

The authors thank Mary V. Jacoski, of HeartWare Inc, for editorial support in the preparation of this manuscript.

Martin Strueber, MD, was a primary investigator in the HeartWare HVAD trial and is an expert consultant for HeartWare Inc. None of the other authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

References (14)

There are more references available in the full text version of this article.

Cited by (51)

  • Sternum-Sparing Left Ventricular Assist Device Insertion Reduces Perioperative Transfusions and Blood Loss: A Single-Centre Canadian Experience

    2022, CJC Open
    Citation Excerpt :

    Although median chest-tube output was only reduced from 575 cc in the FS/HS group to 460 cc in the BMT group, a signal for reduced chest-tube output in the early postoperative period at 12 hours may contribute to decreased transfusion, and provide hemodynamic benefits. Another purported benefit of BMT is improved right ventricular function and safer transplant through virgin sternotomy.8,10-12,21,22 Preserving the pericardium in BMT has been hypothesized to protect right ventricular function by providing a pressure barrier.

  • Percutaneous Decommissioning of Left Ventricular Assist Device

    2018, Heart Lung and Circulation
    Citation Excerpt :

    Minimal access LVAD implantation aims to improve outcomes by minimising surgical insult, and preserving right ventricular function. Minimal access LVAD explantation has been shown to be feasible in recovered patients [3–5]. A review of the evolution of explant strategies was performed to guide our decision to wean the LVAD in our early experience.

View all citing articles on Scopus
View full text