Simplified, less-invasive left ventricular assist device implantation in patients with post-coronary artery bypass grafting

Abstract

Less-invasive left ventricular assist device implantation is becoming the technique of choice for implementation of new-generation heart pumps. The less-invasive technique is particularly useful for patients with a history of cardiac surgical procedures, such as coronary artery bypass grafting. Yet, in redo cases, severe pericardial adhesions may force experienced operators to opt for alternative outflow graft placement, such as in the descending aorta. We propose a surgical technique in which the left ventricular device is implanted through a limited thoracic incision, with the outflow graft anastomosed to the ascending aorta, avoiding collision with coronary bypass grafts. The key element of the proposed technique is a tunnel connecting 2 pleural cavities, in which the outflow graft is placed, entirely bypassing the pericardium.

Less Invasive Reoperative Ventricular Assist Device Insertion for Patients With Patent Bypass Grafts

“…Third routing the OG through the left chest requires much less dissection and tunneling than other approaches, such as the subxiphoid to right chest approach. 2,3 RV failure after LVAD insertion is associated with adverse events, and the prevalence is higher in a reoperative scenario because of bleeding, manipulation around the RV, and bypass graft injury. 4 Compared with a full sternotomy, recent studies support the benefit of a thoracotomy approach in preventing RV failure, [2][3][4][5] and thus it is reasonable to avoid a full sternotomy for LVAD implantation in reoperative cases.…”

“…Other less invasive LVAD insertion techniques for reoperative cases have been reported. 2,3 The described technique includes dissecting the anterior mediastinal and left pleural spaces under direct vision, using a hemisternotomy and thoracotomy, and does not require additional incisions or dissection for tunneling the OG. The descending thoracic aorta or left axillary artery has been used as an alternative anastomotic site for the OG.…”

The role of long-term mechanical circulatory support in the treatment of end-stage heart failure

“…1). The device can be implanted by median sternotomy or by minimally invasive left lateral thoracotomy [3]. Life-long anticoagulant (warfarin) and antiplatelet therapy is mandatory.…”