In-hospital outcomes of a minimally invasive off-pump left thoracotomy approach using a centrifugal continuous-flow left ventricular assist device

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Background

Minimally invasive left thoracotomy (MILT) and off-pump implantation strategies have been anecdotally reported for implantation of the HeartWare ventricular assist device (HVAD). We analyzed our experience with off-pump MILT implantation techniques and compared early in-hospital outcomes with conventional on-pump sternotomy (CS) implantation strategy.

Methods

Between January 2013 and February 2014, 51 patients underwent HVAD implantation and were included in this study. Thirty-three patients had CS, whereas 18 patients underwent off-pump MILT. To compare outcomes of these techniques, a multivariate analysis using propensity score modeling was performed after adjusting for age, INTERMACS, Kormos and Leitz-Miller (LM) scores.

Results

Mean age at implant was 57 (range 18 to 69) years, and overall in-hospital mortality was 8%. Univariate analysis revealed a statistically significant reduction in days on inotropes (p = 0.04), and a trend toward reduced intra-operative blood product administration (p = 0.08) in the MILT group. There was no difference in intensive-care-unit length of stay (p = 0.5), total length of stay (p = 0.76), post-operative blood product administration (p = 0.34) and total time on mechanical ventilation (p = 0.32). After adjusting for age, INTERMACS profile and Kormos and LM scores, no statistically significant differences were observed between the MILT and CS groups.

Conclusions

An off-pump MILT implantation strategy can be utilized as a safe surgical approach for patients undergoing HVAD implantation. Further large collaborative studies are needed to identify advantages of the MILT approach.

Section snippets

Study design

Our investigation was a retrospective analysis of prospectively gathered data from January 2013 to February 2014. The study was approved by the institutional review board of the Vanderbilt University Medical Center. Patients were invividually consented for the surgical approach utilized and agreed to move forward with the proposed implant technique despite the investigational nature of the off-pump left thoracotomy strategy. For all patients in the conventional surgery group (CS group), a

Results

Between January 2013 and February 2014, 51 patients were found to meet our study inclusion criteria and underwent HVAD implantation. Thirty-three patients (26 men, or 79%) had a CS implant, whereas 18 (12 men, or 72%) were approached using a MILT. All patients were implanted for a bridge-to-transplantation indication. Median age at implant was 57 (range 18 to 69) years. The two groups were similar in pre-operative characteristics, including INTERMACS profile and Kormos and LM scores (Table 1).

Discussion

Ventricular assist device surgery has become an integral procedure for the treatment of terminal heart failure.11 HVADs, approved by the U.S. Food and Drug Administration in November 2012 for bridge-to-transplant indications, have been used with greater frequency, with more than 2,500 pumps placed worldwide.12 The surgical approach for HVAD placement has tradionally been a mid-line sternotomy using CPB.10 Although this approach has been successful, it may increase the risk of post-operative

Disclosure statement

D.M. is a paid consultant for HeartWare. The remaining authors have no conflicts of interest to disclose. We thank Dr Martin Strüber (Leipzig, Germany) and Dr Jan Schmitto (Hannover, Germany) for allowing us to visit their centers and develop our strategy for MILT HVAD implantation.

References (35)

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