Minimally Invasive Extrapericardial placement of a Left-ventricular Assist Device
*Muhammad Anwer1,2, Pramod Bonde3,4
1Yale new haven, woodbride, CT; 2Yale New haven Hospital, New Haven, CT; 3Yale new haven, new haven, CT; 4Yale New Haven Hospital, New Haven, CT
Introduction:Left ventricular assist devices (LVADs) involve intrapericardial placement of the outflow graft making their explantation challenging at the time of heart transplantation. Also, the extra volume and pressure of the intrapericardial outflow graft leads to deformation of the right ventricle. To facilitate explantation and prevent alterations in right ventricular hemodynamics, we routinely perform minimally invasive LVAD implantation with extrapericardial placement of the outflow graft.
Methods and results:In 22 patients, following a 5cm long xiphisternal incision, a pocket is made in the preperitoneal plane. A 5cm anterolateral thoracotomy is performed directly over the apex of the left ventricle and the pericardium is divided in inverted T shaped fashion at LV apex. A right anterior mini thoracotomy in 2nd or 3rd intercostal space. Apical coring and myomectomy is performed, Teflon pledgeted Ethibond stiches are inserted in a transverse mattress fashion and LVAD is connected after sewing the ring of inflow cannula. A side-biting clamp is applied to the ascending aorta. An end to side anastomosis is performed under direct visualization. Finally, cardiopulmonary bypass is weaned off and LVAD support is initiated. Sixteen patients had prior cardiac surgical procedure performed. There were no conversions to median sternotomy. One patient needed RVAD. Blood product usage remained low no transfusion (n=15), two packed cells (n=5), three or more (n=2). Average duration at the time of transplant to dissect out the heart was 30 minutes.
Conclusion: Compared to conventional sternotomy, minimally invasive approach offers superior outcomes in terms of RV failure and blood transfusion. Extrapericardial placement facilitates minimizing adhesions around the graft and allowing easy sternal re-entry and intrapericardial dissection.