The Effects of Less Invasive Extra-Pericardial Placement of Left Ventricular Assist Devices on Right Ventricular Failure in the Early Postoperative Period

Abstract

Less invasive extra-pericardial placement (LIEPP) of LVADs is being explored to address post-implant adverse events. We examined the differences in early 90-day right ventricular failure (RVF) between LIEPP versus standard median sternotomy (MS) approaches in a single-center experience. A retrospective analysis of 173 LVAD patients implanted between June 2011 and September 2018 was conducted. Six patients were excluded: four with RVAD placement before LVAD, one with giant cell myocarditis, and one with >40% missing data. LIEPP was performed in 36 patients and 131 had MS implantation. Outcomes for RVF including RVAD need and bleeding were compared using Fisher's test for categorical variables, Mann-Whitney test for continuous variables, and multivariate for cause of RVF. Compared to the MS cohort, the LIEPP group consistent of patients with greater age (62.8 vs 57.9 yrs) p=0.03; higer INTERMACS profile (INTERMACS 1 =72.2% vs 30.5%) p=0.0004; greater IABP use (44.4% vs 26.0%) p=0.03; higher preop BUN (mg/dL) 36.5(25.5 - 56.0) vs 28.0 (19.0 - 41.0) p=0.01; and lower preop hemoglobin (g/dL) 10.0 (8.8 - 11.7) vs 10.6 (9.8 - 12.2) p=0.01. LIEPP showed a significantly lower rate of bleeding through chest tube output (p=<.0001) and tended to require less transfusion (p=0.77). There were no RVADs required post LVAD (p=0.03) with LIEPP and fewer cases of RVF (8.3% vs 13.2%) (p=0.43). Multivariate regression did not reveal a significant association with RVF or RVAD use with LIEPP. LIEPP reduces the early 90-day incidence of RVF and thus need for RVAD. With the integrity of the pericardium maintained, the LIEPP may prevent RV dilation and RVF. Likewise, a reduction in blood product use removes potential influence on pulmonary vascular resistance that can predispose to RVF. These trends were seen despite the worse pre-operative profile of the LIEPP group highlighting the preferred choice of LIEPP for poor surgical candidates.