Adult: Mechanical Circulatory Support
Less-invasive ventricular assist device implantation: A multicenter study

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Abstract

Background

Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach.

Methods

Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation.

Results

The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77).

Conclusions

The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.

Graphical abstract

Retrospective analysis of patients with terminal left heart failure who underwent LVAD implantation through the LIS or CS approach. The LIS approach showed shorter hospital length of stay and lower reexploration for bleeding. There was no difference in mortality between LIS and CS.

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Section snippets

Materials and Methods

Between January 2014 and December 2018, a total of 342 consecutive patients underwent LVAD implantation for end-stage heart failure at 2 high-volume institutions. The patients at both centers were discussed in detail with the heart failure team. The majority of the surgical cases were performed by 2 surgeons. The decision to proceed with sternotomy or LIS approach (hemi-sternotomy or minithoracotomy approach) was based on the operating surgeon's discretion. Both surgical techniques were used

Results

A total of 342 consecutive patients underwent LVAD implantation (HVAD, HMII, and HMIII) due to end-stage heart failure in both institutions. The LIS approach was performed in 101 patients (29.5%). The LIS approach was feasible in all patients, and none of the patients were converted from LIS to CS. The mean age of patients was 59 ± 11 years. The majority of patients were male (307/342 patients, 90%). Follow-up was complete in 100% of the patients with a total LVAD duration support of 420

Discussion

In this multicenter, propensity-adjusted study comparing VAD implantation with the CS compared with the LIS approach, we illustrated that the LIS approach was associated with a lower reexploration rate for bleeding and shorter duration of hospital stay. In addition, there was no significant difference in cumulative incidence of mortality at final follow-up between these surgical techniques (Figure 2).

Mechanical circulatory support systems are considered an important therapy option for patients

Conclusions

LIS is a safe alternative technique for LVAD implantation. It was associated with a lower reexploration rate for bleeding, shorter intensive care unit length of stay, and shorter length of hospital stay. There was no significant difference in incidence of mortality between these techniques. Randomized trials are necessary to confirm our findings.

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    However, even in these studies full sternotomy was used more commonly in the early years and lateral thoracotomy more commonly in later years. Five studies1,3,20,21,23 were multicenter and eight studies11,18-23,27 reported propensity matched or adjusted data for 1,195 patients (410 lateral thoracotomy and 785 sternotomy patients; Table 1). The HeartWare HVAD (Medtronic Inc., USA) was the most commonly implanted device (n = 2,090 [68%]), followed by the HeartMate 3 (n = 622 [20%], HeartMate II (n = 239 [8%]; Abbott, USA), and Jarvik 2000 (n = 93 [3%]; Jarvik Heart, USA).

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K.J., F.S., A.L., and D.S. contributed equally.

Presented at the 40th International Society for Heart and Lung Transplant Anniversary Meeting and Scientific Sessions, April 22-25, 2020, Montréal, Canada.

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