Three-Field LVAD Implantation Completely Avoids Dissection of the Heart in Patients with Previous Sternotomy

Abstract

<h3>Introduction</h3> Less invasive techniques to implant a left ventricular assist device (LVAD) reduce perioperative complications, length of stay, right heart failure, and perhaps even mortality. In this case series we describe a novel three-field implant technique (3FIT) for LVAD for patients with previous sternotomies. This technique employs a left thoracotomy, a subxiphoid incision, and a right thoracotomy or upper ministernotomy. The outflow graft is tunneled from the left thoracotomy to the subxiphoid area and then subsequently to the aorta through the right pleural space. To avoid any possible compression of the outflow graft in the subxiphoid area, an additional bend relief is easily spliced with the original one (Figure). <h3>Case Report</h3> Five patients (4 with previous CABG and one with 3 prior sternotomies) underwent LVAD implantation via the 3FIT. The mean age was 55.4 ± 16.2 years and Heartmate II Risk Score (HMRS) was2.51 + 0.5 (high risk HMRS is > 2.48). Mean pre-operative eGFR was 46+ 14 mL/min. Mean right atrial pressure was 11 + 5 mmHg and pulmonary artery pulsatility index was 3.3+ 2.8. Mean cardiopulmonary bypass time was 142 + 38 minutes. Post-operatively, the mean time to extubation was 10.4 ± 7.5 hours, mean ICU length of stay was 8.6 ± 5.7 days, and mean length of stay was 20.8 ± 4.7 days. No patients had severe or severe-acute right heart failure (RHF) by INTERMACS criteria, and no patients required long term renal replacement therapy. One patient died 16 months post-operatively of chronic heart failure. <h3>Summary</h3> The 3FIT completely avoids dissection and mobilization of either ventricle in patients with prior sternotomies. This is particularly important in patients with poor RV function and patent coronary grafts. Coronary angiography to assess bypass grafts preoperatively is not necessary, especially if renal function is compromised. None of our patients had significant RHF or required long-term dialysis in this high risk group of patients with prior sternotomies.