Effect of Preoperative Cardiac Anatomy and Surgical Approach on HVAD Inflow Position

Abstract

Purpose We assessed the influence of preoperative cardiac anatomy and surgical approach on inflow cannula position in Heartware HVAD recipients. Methods We reviewed pre- and postoperative CT scans and echocardiography. Anatomic variables were chosen based on prior studies: LV end-diastolic dimension (LVEDD), axial plane midline-to-apex distance (ApexDist), and coronal-plane LV outflow tract angulation from horizontal (LVOT angle). Surgical technique was conventional sternotomy (CS) or lateral thoracotomy/hemisternotomy (LTHS). Inflow cannula angular deviation from a line intersecting the apex and mitral orifice center was measured in two planes. Anterior plane deviation is toward the superior or inferior free wall. Lateral plane deviation is toward the septum or lateral wall. Total deviation is the sum of the two. Cutoffs for malposition were deviation ≥ 20 deg in any direction or ≥ 40 deg total. Results 99 HVAD patients (43 CS, 56 LTHS) implanted since 2011 with pre- and postoperative CT were included. LVEDD was larger for LTHS (7.2 vs 6.7 cm, p=0.01). ApexDist and LVOT angle were similar between CS and LTHS. Figure shows inflow position by surgical technique. Inferior-wall deviation was common, while no patient had superior wall-directed malposition. Significantly more septal malposition occurred in CS patients (14% vs 2%; p=0.04). Shorter ApexDist predicted lateral wall malposition (p Conclusion Preoperative CT measurements and surgical approach were associated with different morphologies of HVAD inflow malposition. Surgical planning techniques to optimize inflow position are under study.