The use of LVADs for end-stage heart failure patients as a Destination Therapy device is growing in popularity, largely because transplantation numbers are stagnant and medical therapy has done little to change the prognosis of Class IV or Stage D patients who fail to respond to optimal treatment. However, many of the DT patients are older and sicker than their BTT counterparts and often have had prior cardiac surgery and significant co-morbidities. The risk of the LVAD implantation, therefore, is increased and methods to reduce the risk should be instituted. As such, preoperative maneuvers--such as nutritional optimization, improvement in right heart parameters, correction of hematologic abnormalities, and so forth--have translated into less perioperative problems [
5,
6]. Postoperative maneuvers have similarly resulted into better outcomes as a more formal critical care approach to the complexities of all the organ systems is addressed [
7,
8]. Intraoperatively, any maneuver that can minimize trauma and avoid complication--bleeding or otherwise--is worth exploring. Thus, the alternative technique described above accomplishes the goal of implanting the LVAD without exposing the entire heart. A similar approach was described by Gregoric et al as well as Anyanwu in which a right thoracotomy and left subcostal incision were utilized [
9,
10]. Recently, Schmitto et al described placement of an implantable centrifugal pump using an upper hemisternotomy and anterolateral thoracotomy [
11]. These authors found this approach to be less invasive and less traumatic in terms of potential for intraoperative catastrophes and postoperative bleeding. We found our approach to provide similar advantages and have now adopted our technique for all implants, high risk and otherwise.
The favorable features of the alternative technique described as well as those referenced are several. For example, the LV apex in end-stage heart failure patients is so laterally displaced that a true midline approach requires an extensive lateral dissection for proper orientation of the inflow cannula. On the contrary, the limited lateral thoracotomy is directly over the LV apex making the inflow connection far easier. In addition, the traditional trans-sternal approach requires extensive dissection through scar tissue in redo cases, thereby putting into jeopardy previously placed bypass grafts; the scar tissue dissection alone can result in excessive bleeding even in the absence of previous grafts. Furthermore, inadvertent entry into the right ventricle or other cardiac chamber can be disastrous. These aspects were of particular concern in the first case described. We deliberately wanted to avoid the dense adhesions of the CorCap™, which is an artificial material that fixes firmly to the heart and surrounding tissues. The hazards of reoperating on a patient with a previously placed CorCap™ was well described by Schroder and colleagues during the cardiectomy of the recipient at the time of transplantation [
12].
In summary, we describe an alternative technique of LVAD implantation in high risk DT patients that minimizes the potential for intraoperative complications. The cases themselves are illustrative of this point, however, the high risk nature of the procedure is still readily apparent. Although we avoided potential intraoperative problems, the "high-risk" nature of the case shifted more toward the patient profile than the operative technique. This was poignantly presented by Vitale and others in their manuscript entitled "A call for guidance in the use of left ventricular assist devices in older adults" [
13]. In retrospect, perhaps the lesson of these cases is to apply the technique to a less morbid population where the benefit of the surgical modification may be better appreciated.