Minimally Invasive Left Ventricular Assist Device Insertion with Concomitant Aortic Valve Replacement Despite Prior Sternotomy

Abstract

<h3>Introduction</h3> Minimally-invasive approaches to left ventricular assist device (LVAD) insertion have been described. However, reoperative sternotomy and/or need for concomitant procedures have been regarded as relative contraindications to a minimally-invasive approach. <h3>Case Report</h3> A 61 year-old female with ischemic cardiomyopathy and prior coronary bypass grafting via median sternotomy was deemed an appropriate candidate for LVAD insertion. While preoperative echocardiography demonstrated mild aortic insufficiency, intra-operative imaging revealed moderate aortic insufficiency. Intra-operatively, the aorta was accessed via a partial upper sternotomy to the 4^th intercostal space. The ventricular apex was accessed through a left anterolateral thoracotomy. Cardiopulmonary bypass was established via an aortic cannula inserted via the ascending aorta and a multi-stage venous cannula inserted into the right femoral vein. Cardioplegia was administered first via an antegrade aortic root catheter, and then later via retrograde catheter and direct coronary ostial cannulation during the valve replacement. The aortic valve was replaced with a 21-mm bioprosthetic valve via the partial sternotomy (Fig A). After aortotomy closure, the cross-clamp was removed and the heart re-perfused. An apical ventriculotomy was then created and the LVAD inflow cannula was inserted into the left ventricle and secured to the sewing ring (Fig B). The outflow graft was tunneled to the upper sternotomy and anastomosed to the aorta using a side-biting clamp. The postoperative course was notable for pneumonia leading to temporary re-intubation. She otherwise did well, and was discharged home on post-LVAD day 23. <h3>Summary</h3> Both a history of a prior sternotomy and the need for concomitant procedures present challenges to use of minimally-invasive approaches for LVAD insertion. Here, we demonstrate that concomitant AVR can be safely performed along with LVAD insertion in a reoperative setting.