Commentary: The principal of the five P's.

Abstract

Central MessageLimited incisions may improve outcomes in selected patients needing device exchange. Planning ahead will optimize results regardless of approach.See Article page 94. Limited incisions may improve outcomes in selected patients needing device exchange. Planning ahead will optimize results regardless of approach. See Article page 94. Left ventricular assist device (LVAD) exchange remains a challenging procedure fraught with technical, anatomic, medical, hematologic, and logistical difficulties.1Austin A. Maynes E. Gadda M. O'Malley T.J. Morris R.J. Shah M.K. et al.Continuous-flow LVAD exchange to a different pump model: systematic review and meta-analysis of the outcomes.Artif Organs. 2021; 45: 696-705Google Scholar The proportion of destination therapy LVAD implantations increases, and bridge to transplant patients are waiting longer for transplant. Accordingly, the number of patients at risk for needing exchange grows, and optimizing outcomes for this vulnerable population is more important than ever. Alternative approaches to LVAD exchange, such as thoracotomy, partial sternotomy, and subcostal, have yielded promising results in well-selected patients. In this issue of JTCVS Techniques, Osho and D'Alessandro2Osho A. D'Alessandro D. Approaches to ventricular assist device exchange: resternotomy versus limited incisions.J Thorac Cardiovasc Surg Tech. 2022; 12: 94-99Google Scholar discuss scenarios leading to LVAD exchange and the current surgical options. Rather than a one-size-fits-all strategy, they propose thoughtful consideration of all available approaches, weighing patient, device, disease, and institutional factors. The authors correctly point out the importance that indication for exchange plays in the choice of approach. Technical considerations are thoroughly addressed, including a timely section on HeartWare (Medtronic) to HeartMate III (Abbott) exchange. Despite a paucity of data comparing resternotomy versus alternative incisions for the latest devices, intuition and the literature support the putative benefits of more limited tissue dissection in patients who are candidates for such approaches.3Agarwal R. Kyvernitakis A. Soleimani B. Milano C.A. Davis R.P. Kennedy J.L. et al.Clinical experience of HeartMate II to Heartware left ventricular assist device exchange: a multicenter experience.Ann Thorac Surg. 2019; 108: 1178-1182Google Scholar Although resternotomy will remain an important and sometimes the most feasible approach to LVAD exchange, surgeons should be open to “limited incisions” when the problem can be fully addressed and the patient is a candidate. If your program is considering adding these strategies to your toolbox, many steps can help prepare for these uncommon but inevitable scenarios long before they arise. Prevention of device exchange obviously comes first. Careful attention to inflow cannula and outflow graft geometry, meticulous sterile technique, and patient education regarding anticoagulation and driveline care are crucial to avoid indications for exchange. Preparing for reentry or exchange, even in destination therapy patients, by limiting dissection and covering the pump and outflow graft, is worth the additional time during the index operation. Performing or simply observing LVAD implantation using the same alternative approaches, thoracotomy, partial sternotomy, and bithoracotomy, will familiarize the surgeon with the exposure and technical pitfalls in a premeditated, nonredo, possibly less urgent context. Regardless of the approach, when it comes to LVAD exchange, keep in mind the adage popularized by James Baker, “Prior Preparation Prevents Poor Performance.”4Kilborn P. Washington Talk: The Secretary of the Treasury; James Baker Likes the Odds of Staying Where He Is. New York Times, April 9, 1987.https://www.nytimes.com/1987/04/09/us/washington-talk-secretary-treasury-james-baker-likes-odds-staying-where-he.htmlDate accessed: November 12, 2021Google Scholar Approaches to ventricular assist device exchange: Resternotomy versus limited incisionsJTCVS TechniquesVol. 12PreviewThe prevalence of end-stage heart failure (HF) is on the rise in the United States, matching concurrent increases in the age of the population and the rates of comorbid conditions such as obesity.1 Although heart transplantation remains the preferred treatment option for patients with end-stage heart failure, donor hearts remain a limited resource with demand that significantly outweighs supply. Left ventricular assist devices (LVADs) provide a viable option for patients with HF, with each new device generation offering improved survival and decreased occurrence of complications. Full-Text PDF Open Access