Robotic Left Ventricular Assist Device Implantation Using Left Thoracotomy Approach in Patients with Previous Sternotomies

Abstract

Left ventricular assist devices (LVADs) are commonly used as either a bridge-to-transplant or a destination therapy. The traditional approach for LVAD implantation is via median sternotomy, but many candidates for this procedure have a history of failed cardiac surgeries and previous sternotomy. Redo sternotomy increases the risk of heart surgery, particularly in the setting of advanced heart failure. Robotics facilitates a less invasive approach to LVAD implantation that circumvents some of the morbidity associated with a redo sternotomy. We compared the outcomes of all patients at our institution who underwent LVAD implantation via either a traditional sternotomy or using robotic assistance. The robotic cohort showed reduced resource utilization including length of hospital stay and use of blood products. As the appropriate candidates become elucidated, robotic assistance may improve the safety and cost-effectiveness of reoperative LVAD surgery.

Minimally-invasive LVAD Implantation: State of the Art

“…Based on the literature review, the common denominator of the various minimal-invasive implantation techniques is the avoidance of full sternotomy, which represents a common trend in cardiac surgery. Minimal-invasive LVAD implantation is a combination of accessing the apex of the left ventricle via thoracotomy, creating a pump pocket [ 18 , 24 - 26 , 28 - 30 ] and a choice of possible outflow graft anastomosis positions [ 18 , 24 , 34 - 37 ]. The choice of procedure is contingent upon the anatomical situation of the patient.…”

“…A variation of outflow graft anastomosis positions, to major arteries of the aortic arch or the descending aorta, offer alternative approaches in challenging cases e.g. porcelain aorta [ 18 , 24 , 34 - 37 ]. Yet, placing the outflow graft to other structures than the ascending aorta may result in flow turbulences or stasis leading to thrombogenesis [ 38 - 40 ].…”

“…Robotic-assisted implantation of ventricular assist devices is another step towards further minimizing the surgical trauma of LVAD implantation [ 37 ].…”

“…Khalpey et al . introduced the technique of robotic-assisted LVAD implantation after pectoral muscle flap, thereby preserving the flap for transplantation [ 37 ].…”

Off Pump Robotic-Assisted LVAD (HeartWare, HVAD) Placement via Left Mini Thoracotomy

“…5 Successful LVAD placement through a robotic-assisted left mini thoracotomy has been previously described by our group and found to be associated with decreased hospital stay and blood product transfusions compared with median sternotomy approaches. 6 The use of this approach is advantageous in that it allows the graft to lie in an anatomic location with anastomosis in the standard location on the ascending aorta while avoiding the morbidity associated with a redo median sternotomy.…”