Transcervical LVAD Outflow Graft Implantation as Sternotomy Free Procedure: Proof-of-Concept

Abstract

Minimally invasive methods to implant left ventricular assist devices (LVAD) have emerged as alternatives to the classic median sternotomy as they have been shown to decrease bleeding and periprocedural complications, plus speed up recovery and make future sternotomies easier. While implantation of a centrifugal LVAD within the LV apex can be performed via a left thoracotomy, the outflow graft anastomosis to ascending aorta is still routinely done via upper hemi-sternotomy which, although limited, has some of the above disadvantages. We present a technique of transcervical outflow graft implantation which completely avoids sternotomy. This is a proof-of-concept implantation performed on a cadaveric model. The procedure is facilitated by a novel access system (CoreVista® Retractor, CardioPrecision Ltd, Glasgow UK) designed for surgery via a transcervical approach. This device comprises a frame fixed to the operating table to which a disposable transcervical retractor with inbuilt illumination modes used for the different steps of the procedure is attached plus an HD display offering optimal views. The technique can be broken down into a number of reproducible steps: transverse neck incision, retractor insertion, sternal elevation, illumination, dissection of anterior mediastinum and exposure of aorta. The outflow graft is pulled into the field and, after trimming to avoid kinking, a side clamp is placed on the aorta and the graft is sutured in continuous fashion. This is greatly aided by the retractor illumination and HD visualisation on-screen. Sutures are tied, clamp released, haemostasis confirmed, retractor removed and the small neck incision closed. This proof of concept demonstrates that a sternotomy-free implantation of a LVAD is feasible and should prove reproducible with the help of the novel transcervical access system. The approach may also be suitable for implantation of an axial flow pump without the current limitations imposed by access vessel size.