Subcostal Approach Research Articles

Subcapsular local anesthesia approach in percutaneous liver biopsy: less pain, more comfort

Background/aimTo compare the subjective level of pain in patients who underwent an ultrasound-guided percutaneous liver biopsy (PLB) after either pericapsular anesthesia (PA) or subcapsular anesthesia (SA), based on the numeric rating scale (NRS).Materials and methodsA total of 323 patients, mean age 51, range 21–82 years; 160 (49.5%) male, referred to the Interventional Radiology Clinic of Kocaeli University Faculty of Medicine for image-guided PLB, between June 2019 and May 2020 were included and randomized into two groups by anesthetic type; the first (n = 171) consisted of patients undergoing SA while the second (n = 152) included patients undergoing PA. The intensity of pain at 0, 1, and 6 h after PLB was evaluated between the groups using NRS.ResultsAt hours 0, 1, and 6, the median [range] NRS scores in the subcapsular and pericapsular groups were 2 [1–2] versus 3 [2–4] (P < 0.001), 1 [0–1] versus 1 [1–2] (P < 0.001), and 0 [0–0] versus 1 [0–1] (P < 0.001), respectively. Subgroup analysis revealed that the patients who underwent the subcostal procedure with subcapsular anesthesia reported the lowest pain scores and intercostal procedure with pericapsular anesthesia reported the worst pain scores for each time point: 0 h 1 [1–2] versus 3 [3–4], P < 0.001; 1 h 1 [0–1] versus 1 [1–2], P < 0.001; and 6 h 0 [0–0] versus 0 [0–1], P < 0.001, respectively.ConclusionSubcapsular anesthesia is a well-tolerated procedure compared to a pericapsular procedure. Furthermore, the application of a subcapsular anesthetic with a subcostal approach was reported to result in the lowest pain and greatest patient comfort.

To Study The Correlation Between Preoperative Inferior Vena Cava Diameter And Intraoperative Hypotension During Spinal Anaesthesia In Caesarean Section

BACKGROUND: Assessment of maternal intravascular volume status during and after gestation is most crucial in the setting of complications that affect hemodynamic stability. The goal of the perioperative fluid management is to avoid acute kidney injury due to hypovolemia and hypotension due to spinal anaesthesia. Ultrasound measurements of dynamic change in inferior vena cava diameter (IVC) and collapsibility index are used to predict and prevent the hypotension after spinal anaesthesia.OBJECTIVES: To correlate the IVC diameter in expiration and incidences of intraoperative hypotension after spinal anaesthesia in full term pregnant patients posted for elective caesarean section.MATERIALS AND METHOD: Total 50 young female patients having full term pregnancy scheduled for elective caesarean sections were included in the study after taking informed consent. Preoperative assessment of all patients was done. Preoperative inferior vena cave diameter in expiration was measured by ultrasound guidance by subcostal approach. Spinal anaesthesia was given with injection bupivacaine heavy 0.5% 2ml between L3-L4 subarachnoid space after taking all aseptic precaution. Pulse, blood pressure was measured at regular interval. Incidence of intraoperative hypotension, bradycardia was noted. Results were expressed as mean ±SD and analysed by paired’ test and correlation coefficient was calculated.RESULTS: The mean inferior vena cava diameter in expiration was 17.4 ± 0.04 and collapsibility index was less than 36 in 80% of patients, and only one patient had developed hypotension after spinal anaesthesia. Correlation coefficient was -0.9.CONCLUSION: Preoperative inferior vena cava measurement is a reliable predictor of hypotension after spinal anaesthesia.

Subxiphoid and subcostal thoracoscopic surgical approach for thymectomy.

The continuous evolvement of minimally invasive thymectomy over the last decades has potential advantages over trans-sternal thymectomy with similar oncologic outcomes of thymoma and complete remission for myasthenia gravis patients. A variety of different minimally invasive approaches have been described previously. The aim of this article is to present our subxiphoid and subcostal approaches in thymectomy for patients with myasthenia gravis and thymomas and to investigate the early surgical outcomes of these patients. A retrospective analysis was performed of 95 patients who underwent thymectomy via a subxiphoid and subcostal approach for MG and/or thymoma at our department during the period of 2015 to 2017. The clinical characteristics and early surgical outcomes of these patients were reviewed and analyzed. Complete thymectomy and extended thymectomy was accomplished through the subxiphoid and subcostal approach in 93 of the 95 (97.9%) patients. Two patients (3.2%) required conversion to sternotomy for the invasion of a thymoma. The mean operative time was 109min (range 70-170min), with the mean estimated blood loss of 47ml (range 20-350ml). Postoperative complications included two cases of myasthenic crisis: one case of pleural effusion and one case of wound infection. In a mean follow-up of 31months no patients showed recurrence of the tumor. In 41 MG patients followed up for 31months, the improvement rate was 87.8% and the rate of complete remission was 29.3%. Subxiphoid and subcostal thoracoscopic thymectomy may be a safe and feasible approach for treating MG and anterior mediastinal tumors.

Laparoscopic Right Adrenalectomy After Superior Heminephrectomy in a Child

Introduction: Laparoscopic adrenalectomy (LA) is widely described in adult population since its first report by Gagner et al. in 1992.1 In contrast, its applicability in pediatric malignancy remains unsettled. According to current evidence, LA in children is acceptable for resection of pheochromocytomas,2 benign tumors, and adrenal hyperplasia.3 The authors present a video of a challenging laparoscopic right adrenalectomy in a child after homolateral superior polar heminephrectomy. Materials and Methods: This is a case of an 11-year-old girl with LiFraumeni syndrome. She had a past medical history of a central nervous system glioma treated when she was 4 years old. Six years later, a nodule on the upper pole of the right kidney with malignant features on imaging was diagnosed, and she underwent right superior heminephrectomy through a subcostal retroperitoneal approach. The specimen revealed that it was an eosinophilic renal carcinoma. One year later, during follow-up, a new nodule on the right adrenal gland was found. Because of the patient's history and malignant risk, she was proposed to tumor excision using a minimally invasive approach. During laparoscopy, important adhesions between the abdominal wall, the kidney, and the right lobe of the liver were found. After careful liberation and dissection, the adrenal tumor was found and excised. The postoperative course was uneventful and was discharged on the second postoperative day. After 1 year, the girl is doing well and is still under surveillance for further tumor development. Conclusion: A laparoscopic approach transforms a major surgery that requires a significant abdominal incision to operate in a difficult access area into a relatively simple and safe procedure. Particularly in patients in whom further surgeries are expected during their lifetime, a minimally invasive approach grants less future iatrogenic complications because of diminished risk for adhesion formation. No competing financial interests exist. Runtime of video: 7 mins 29 secs

Safety of Upper Pole Puncture in Percutaneous Nephrolithotomy with the Guidance of Ultrasonography versus Fluoroscopy: A Comparative Study

Introduction: The aim of this study was to compare the safety of ultrasonography-guided (UG) puncture and fluoroscopy-guided (FG) upper pole access (UPA) in percutaneous nephrolithotomy (PCNL). Methods: Consecutive patients with a solitary UPA were enrolled into the study from 2012 to 2020 and analyzed in a retrospective manner. In total, 177 patients were divided into 2 groups according to the method during the puncture phase of the access: FG (n = 105) and UG (n = 72). The UG and FG groups were compared in terms of complications (i.e., pleural injury and blood transfusion rate) and surgical outcomes. Results: Gender, side, grade of hydronephrosis, type of access (i.e., supracostal vs. subcostal), Guy’s stone score, age, stone diameter, skin-to-stone distance, and stone density were similar in the 2 groups (p > 0.05). Only in 25.9% of cases, UPA was done using a subcostal approach. The overall complication rates were similar between the groups (p > 0.178). For the UG and FG groups, the rate of pleural injury (8.5 vs. 4.1%) and the blood transfusion rate (8.5 vs. 2.8%) were also similar (p > 0.05). The fluoroscopy time and mean hemoglobin drop were significantly lower in the UG group than in the FG group (134.2 vs. 82.2 s, respectively, p = 0.001; 20.8 ± 9.8 vs. 16.8 ± 7.9 g/L, respectively, p = 0.001). Stone-free rate (SFR) was also similar in the FG and UG groups (77.1 vs. 75.0%, respectively, p = 0.742). Conclusion: While it is commonly expected that the complication rates are lower in UG puncture for UPA in PCNL than they are in FG puncture, the present study failed to show this difference. However, the radiation exposure time seemed to be lower in UG puncture than FG puncture and had a similar stone-free rate (SFR) for UPA in PCNL.

Comparison between the ultrasound-guided erector spinae block and the subcostal approach to the transversus abdominis plane block in obese patients undergoing sleeve gastrectomy: a randomized controlled trial.

Pain control in the morbidly obese has presented as an anesthetic challenge. The aim of this study is to assess the analgesic efficacy of ultrasound guided bilateral erector spinae block compared to bilateral subcostal transversus abdominis plane block. A prospective randomized, double-blinded controlled study was conducted at Kasr Alainy Hospital on 66 patients scheduled for laparoscopic sleeve gastrectomy. Patients were randomly allocated into three groups and received general anesthesia: bilateral erector spinae block at the level of T9 or bilateral subcostal transversus abdominis block or opioid analgesia (control group). The primary outcome was pain assessment by Visual Analogue Scale. Visual Analogue Scale was lower in the erector spinae and transversus abdominis groups compared with the control group throughout the first 12 postoperative hours (P≤0.001). Visual Analogue Scale was lower in the erector spinae group in relation to control group at 18 postoperative hours (P=0.034). Visual Analogue Scale in the erector spinae group was significantly lower compared to transversus abdominis at the 12 postoperative hours. Twenty-four-hour postoperative pethidine consumption was higher in the control group (median 150, IQR 100-200) compared to both erector spinae (median 0, IQR 0-50) and transversus abdominis (median 50, IQR 0-100) groups (P<0.001). Erector spinae group showed less pethidine consumption than transversus abdominis group. Ultrasound-guided single-shot T9 erector spinae plane block lowers postoperative pain scores, and reduces intraoperative and postoperative opioid consumption compared with both the subcostal approach transversus abdominis plane block and the control group in obese patients that had undergone sleeve gastrectomy.

A Novel Echocardiographic Window for the Evaluation of the Outflow Graft in HeartMate 3 Left Ventricular Assist Devices

Interrogation of the left ventricular assist devices (LVAD) outflow graft with trans thoracic echocardiography (TTE) is often limited by poor windows. We describe a novel subcostal TTE approach to assess the outflow graft in patients with HeartMate 3 LVAD. The outflow graft was visualised using a shallow subcostal window with the probe tilted almost parallel to the abdominal wall. This new subcostal window was compared to the right parasternal window. The velocity time integral (VTI) of the Doppler between the artificial pulse every 2 seconds was used to calculate total pump flow (litres per minute) = VTI x cross-sectional area of outflow graft x 30 'beats per minute'. Pump parameters were recorded at the same time. 35 consecutive patients with HeartMate 3 LVAD were included (Age: 53±4 years; 89% males; body mass index 26±1kg/m2).The outflow graft could be visualised in 28/35 patients (80%) with this subcostal window compared to 12/35 (34%) patients with parasternal window (p<0.05). The colour Doppler and VTI of a patient with normal and partially occluded outflow graft are shown in FIGURE 1a, 1b and 1c respectively. The latter shows high velocity Doppler compared to normal. The calculated pump flow correlated with the displayed pump flow (R2=0.69, p<0.001), but agreement on the Bland-Altman plot is modest [FIGURE 2]. 'Pulsatility' based on the ratio of s and d flow on Doppler correlated with the displayed pulse index (R2=0.52, p<0.001). A novel shallow subcostal echocardiographic window can interrogate the LVAD outflow graft in patients with HeartMate 3 LVAD.

Sonographic Association of Cholelithiasis with Obstructive Jaundice in Adult Patients

Background: Cholelithiasis is the commonest cause of obstructive jaundice and for the investigation of cholelithiasis and obstructive jaundice ultrasound is a gold standard modality. Obstructive jaundice is generally due to biliary obstruction, which is a blockage of the common bile duct or any duct that carries bile from the liver to the gallbladder and then enters into the small intestine. Objective: To determine sonographic association of cholelithiasis with obstructive jaundice in adult patients. Methodology: A cross sectional study was conducted among 138 individuals. All were young adults within the age range of 18-35 years. Data was collected from Civil Hospital Gujranwala city, by using simple random sampling technique. The examination was done with Toshiba Xario 3.5-5MHz curvilinear transducer. Gallbladder scan was started with the patient in the supine position from both subcostal and intercostal approaches. It was analyzed through SPSS version 24.0 and presented through frequency and percentages. Results: Total 138 individuals were included in this study. Out of 138 subjects, 69 individuals with cholelithiasis out of 69, 24 individuals with obstructive jaundice. And other 69 individuals without cholelithiasis in which 26 subjects presented with jaundice. It was found that females (51.4%) were more commonly affected than males (48.6%) .Conclusion: It was concluded that cholelithiasis is one of the main causes of obstructive jaundice and ultrasound can easily diagnose the cases of cholelithiasis. It was found that females were more commonly affected than males. Keywords: cholelithiasis, obstructive jaundice, jaundice, ultrasound. DOI: 10.7176/JHMN/72-04 Publication date: March 31 st 2020

A case of severe left main coronary artery stenosis diagnosed by transthoracic Doppler echocardiography: coronary blood flow recordings by subcostal approach

A case of severe left main coronary artery stenosis diagnosed by transthoracic Doppler echocardiography: coronary blood flow recordings by subcostal approach

P968 Subcostal M-mode echocardiography of tricuspid annular motion helps recogntion of heart arrhythmias

Abstract Recognition of supraventricular arrhythmias and differention between supraventricular and ventricular rhythm abnormalities in ECG can sometimes be difficult due to indiscernible P wave. 1D echocardiography of tricuspid annular motion can quickly and reliably detect atrial contraction (Picture 1, figure 1a.) which has a characteristic appearance for majority of supraventricular arrhythmias. Since subcostal approach is almost always reliable, it allows simple and rapid recognition and differentiation between supraventricular arrhythmias, e.g. atrial fibrillation (Picture 1, figure 1b.) from atrial flutter and nodal rhythm. Detection of atrial contractions enables recognition of AV dissociation in ECG, which helps in differentiation between supraventricular and ventricular arrhythmias. This technique is also useful in checking the function and mechanical efficiency of atrial pacing. Figure 1a. Atrial contraction / sinus rhythm RA = right atrium A = atrial contraction Figure 1b. Atrial fibrillation RA = right atrium a = fibrillary contractions Abstract P968 Figure. Picture 1

Assessment of M-mode index of obstruction in patients with chronic obstructive pulmonary disease

Background Diaphragm motion during forced expiration can be analyzed using M-mode ultrasound in an anterior subcostal approach. Maximal expiratory diaphragmatic excursion and forced expiratory diaphragmatic excursion in the first second physiologically mimic forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), respectively, and may be used as a marker of obstruction. Aim The aim of the work was to assess the role of the M-mode index of obstruction (MIO) as a screening test (tool) for chronic obstructive pulmonary disease (COPD). Patients and methods This case–control study involved 200 participants (100 patients with COPD and 100 age-matched and sex-matched healthy controls). The authors performed spirometry and the diaphragm ultrasonography, during forced expiration. MIO was calculated as the slope of diaphragmatic excursion in first second/slope of diaphragmatic excursion at end of expiration. Results Diaphragmatic excursion was significantly lower in COPD group than control group (4.27±1.49 vs 5.36±1.67 for slope in the first second of expiration, 4.82±1.55 vs 5.72±1.57 for maximum slope at the end of expiration, 4.42±1.53 vs 5.44±1.69 for velocity of diaphragm contraction in first second, and 2.40±1.04 vs 3.52±1.26 for velocity of diaphragm contraction at the end of expiration; P= Conclusion Diaphragmatic excursion during forced expiration is significantly decreased in COPD in comparison with the control group. MIO is significantly lower in COPD in comparison with control and significantly correlated with FEV1/FVC.

Safety and efficacy of supracostal superior calyceal approach for percutaneous renal surgery.

Supracostal access is avoided for fear of potential intrathoracic complications and subcostal approach is favored as it carries minimal or no risk of intrathoracic complication. The aim of this study was to evaluate safety and efficacy of supracostal approach for percutaneous renal surgery. A total of 60 cases were enrolled and studied prospectively in this study. The patients had upper (n=10), and lower (n=12) calyceal, pelvic (n=12), proximal ureteral (n=14) stones, and pelviureteric junction obstruction (n=12). All the punctures were made by urologist under fluoroscopy. All the punctures were made between 11th and 12th ribs (supra-12th); none of the punctures was made above 11th rib. The overall complication rate in our study was 26.7%. Four patients (6.7%) had pleural rupture and all the four presented with hydrothorax. The other complications included intraoperative hemorrhage in 1 (1.7%), and pelvic perforation in 1 patient (1.7%), Amplatz sheath migration/loss of tract was detected in 1 (1.7%), postoperative fever in 2 (3.3%), prolonged hematuria in 3 (5%) and residual disease in 4 (6.7%) patients CONCLUSION: Supracostal approach should be used whenever indicated which was found to be both effective and safe as far as intrathoracic and other complications are concerned.

Dissection of left recurrent laryngeal area by SP system in subcostal approach

Dissection of left recurrent laryngeal area by SP system in subcostal approach

Transversus Abdominis Plane Block: A Narrative Review.

In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.

The safety and feasibility of a single incision in simultaneous resection for patients with colorectal cancer liver metastases.

The approach of performing a simultaneous resection for patients with colorectal cancer liver metastases has been lauded universally, but the operation procedures have differences. In general, colorectal lesions are removed laparoscopically; however, some liver metastases cannot be resected under laparoscopy. For these patients, the traditional approach of performing a simultaneous resection which utilizes the inferior abdominal midline incision and the right subcostal incision is preferred. In this study, we assessed the safety and feasibility of the single right subcostal incision approach for patients with either rectal or sigmoid colon cancer and liver metastasis who underwent simultaneous resection. A total of 85 patients with rectal or sigmoid colon cancer and liver metastases who underwent simultaneous resection from January 2012 to December 2016 in the Cancer Hospital Chinese Academy of Medical Sciences were identified. Clinicopathological data, as well as operative and perioperative outcomes, were collected and analyzed retrospectively. Overall, 42 patients were included in this study, 26 (61.9%) patients underwent simultaneous resection with a single surgical incision (right subcostal incision), and 16 (38.1%) underwent simultaneous resection with dual surgical incisions (inferior abdominal midline incision and right subcostal incision). Compared to the dual-incision approach, the single-incision approach had a shorter operation time (328.0 vs. 420.0 min, P=0.006) but had no significant differences in total hospitalization time, postoperative hospitalization time, intraoperative blood loss, time of postoperative drainage tube extraction, time to the first postoperative bowel movement, and postoperative complications (P>0.05). The single-incision approach (right subcostal incision) is feasible and safe for patients with either sigmoid colon or rectal cancer and liver metastases.

Ultrasound Subcostal Approach Transversus Abdominis Plane Block in Morbidly Obese Patient

As general population of obese patients in Malaysia rapidly increases, more obese patients are requiring anaesthesia for various operative procedures. Obesity is associated with anatomical and physiological differences and co-morbidities that influence on the choices of anaesthesia care. A surgical case with general anaesthesia is used as a basis of discussion. A 37-year-old female, history of untreated hypertension and gastrooesophageal reflux disease (GORD), BMI of 41 admitted for laparoscopic cholecystectomy for symptomatic cholelithiasis under general anaesthesia. She presented with pain at the upper right abdomen and associated with bloated abdomen, nausea and vomiting after intake of meals. General anaesthesia and right ultrasound-guided transversus abdominis plane (TAP) block for abdominal wall blocks via subcostal approach was performed. Operation was removal gallstones in the common bile duct via laparoscopic approach. Post operation patient was extubated successfully. She was prescribed paracetamol 1g 4 hourly and started on fentanyl patient-controlled analgesia (PCA) for next 2 days. In this case report, there is the description of the application of TAP block which when used in obese abdominal surgical procedure, can provide excellent postoperative pain relief, early mobilization and recovery.

Analgesic effect of the ultrasound-guided subcostal approach to transmuscular quadratus lumborum block in patients undergoing laparoscopic nephrectomy: a randomized controlled trial

BackgroundQuadratus lumborum block (QLB) is an effective analgesia that lowers opioid consumption after lower abdominal and hip surgeries. The subcostal approach to transmuscular QLB is a novel technique that can provide postoperative analgesia by blocking more dermatomes. The aim of this study is to evaluate the efficacy and viability of subcostal approach to QLB after laparoscopic nephrectomy.MethodsSixty patients who underwent laparoscopic nephrectomy were randomly divided into the subcostal approach to QLB group (QLB group, n = 30) and the control group (C group, n = 30). All patients underwent ultrasound-guided subcostal approach to QLB in an ipsilateral parasagittal oblique plane at the L1–L2 level. The QLB group received 0.4 cc/kg of 0.3% ropivacaine, and the C group received 0.4 cc/kg of 0.9% saline. Postoperatively, a patient-controlled intravenous analgesic pump with sufentanil was attached to all the patients. The primary outcome was sufentanil consumption within the first 24 h after surgery. The secondary outcomes included the Ramsey sedation scale (RSS) scores and Bruggemann comfort scale (BCS) scores 6 h (T1), 12 h (T2), and 24 h (T3) after surgery, intraoperative remifentanil consumption, number of patients requiring rescue analgesia, time to recovery of intestinal function, mobilization time after surgery, and presence of side effects.ResultsSufentanil consumption within the first 24 h after surgery was significantly lower in the QLB group than in the C group (mean [standard deviation]: 34.1 [9.9] μg vs 42.1 [11.6] μg, P = .006). The RSS scores did not differ between the two groups, and the BCS scores of the QLB group at T1 and T2 time points was significantly higher than those of the C group(P<0.05). The consumption of remifentanil intraoperatively and the number of patients requiring rescue analgesia were significantly lower in the QLB group (P<0.05). Time to recovery of intestinal function and mobilization time after surgery were significantly earlier in the QLB group (P<0.05). The incidence of postoperative nausea and vomiting was significantly lower in the QLB group (P<0.05).ConclusionsThe ultrasound-guided subcostal approach to QLB is an effective analgesic technique in patients undergoing laparoscopic nephrectomy as it reduces the consumption of sufentanil postoperatively.Trial registrationChiCTR1800020296 0 (Prospective registered). Initial registration date was 22/12/2018.

Anatomic Approach Does Not Influence Technical Outcomes of Pericardiocentesis in the Pediatric Population

BACKGROUND: The standard approach to pericardiocentesis is a subcostal approach with echocardiographic guidance. Hepatomegaly and noncircumferential effusions warrant nonstandard approaches to drain effusions; echocardiographic guidance has made other, less traditional, non-subcostal approaches feasible. METHODS: All pediatric patients undergoing pericardiocentesis from August 2008 to June 2016 at a tertiary care hospital were included. Procedure-related complications, approach to procedure, the location …

Clinical Experience of HeartMate II to HeartWare Left Ventricular Assist Device Exchange: A Multicenter Experience

Despite improvements in pump design and durability, left ventricular assist device patients still suffer from life-threatening complications such as pump thrombosis (PT) and infection, often necessitating device exchange. Surgical exchange from HeartMate II (HM2; Abbott, Pleasanton, CA) to another HM2 is safe and associated with low mortality, but recurrent device thrombosis rates are high. Switching from axial-flow to centrifugal-flow pump, such as the HeartWare ventricular assist device (HVAD; Medtronic, Framingham, MA) may offer certain advantages due to it being a smaller, newer generation device, although there are limited data to support this strategy. Herein, we aimed to assess the surgical approach and feasibility, safety, and outcomes of surgical exchange from HM2 to HVAD. We evaluated HM2 patients who underwent device exchange to HVAD due to PT or infection at 4 large-volume left ventricular assist device implant centers. Twenty-four patients underwent HM2 to HVAD exchange due to PT (92%) and refractory infection (8%). Patients were male (75%), white (88%), with ischemic cardiomyopathy (54%), Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) scale level 1-3 (90%), and destination therapy (62%). The majority underwent redo-sternotomy (79%) and the remainder underwent minimally invasive thoracotomy with subcostal approach. The existing HM2 outflow graft was maintained in 79% of cases. Recurrent PT was noted in 9% of patients. Mortality was 8% at 30 days and 33% at 1 year. The surgical exchange from a HM2 to HVAD is safe and feasible, despite the differences in device specifications and surgical adaptation required. Newer-generation pumps are increasingly considered for exchange in the setting of HM2 device complication, and increasing experience with modified surgical approaches may be valuable in the current era.

A subcostal approach is favorable compared to sternotomy for left ventricular assist device exchange field of research: artificial heart (clinical).

This is a single-center retrospective study to summarize clinical outcomes of patients requiring surgical continuous-flow left ventricular assist device (HeartMate II) exchange. The patients who underwent HeartMate II exchange were divided into two groups either via a subcostal approach (SC group) or a full sternotomy (FS group). The exclusion criteria of a subcostal approach for device exchange included the presence of outflow graft obstruction, and/or the need for concomitant cardiac procedures. Among 277 consecutive patients who underwent HeartMate II implantation from July 2008 to December 2015, 25 patients (9.0%) required device exchange (SC group; N = 13, FS group; N = 12). The SC group, compared to the FS group, had a shorter operative time (200.6 ± 31.4min vs 534.2 ± 123.9min; P < 0.001), shorter cardiopulmonary bypass time (33.1 ± 22.0min vs 151.5 ± 53.1min; P < 0.001), fewer blood transfusion (0.31 ± 0.48 units vs 4.67 ± 3.65 units; P = 0.002). The SC group had lower incidence of postoperative prolonged intubation (> 24h) (7.7% vs 90.9%, P < 0.001), tracheostomy (0.0% vs 41.7%, P = 0.015), acute kidney injury requiring dialysis (0.0% vs 33.3%, P = 0.039). In-hospital mortality was 0.0% (0/13) in the SC group and 16.7% (2/12) in the FS group (P = 0.220). In conclusion, a subcostal approach was associated with shorter operative time, fewer blood transfusions, and less postoperative complications, compared to full sternotomy. A subcostal approach, if feasible, is preferred for HeartMate II device exchange.