Minimal-Invasive versus Sternotomy for LVAD Destination Therapy in Elective Patients

Objectives: LVAD as Destination Therapy (DT) is an acceptable strategy for non-transplantable end-stage heart failure patients. However, it is not yet clear if the minimal-invasive implant technique has advantages to the conventional technique via sternotomy. Especially in the older and sicker destination therapy population with higher frailty the need for a less invasive operation is preexisting. In this study we compare the minimal-invasive with the conventional LVAD implant technique in destination patients.

Methods: In 39 patients implantation of the HVAD-LVAD (HeartWare, Framingham, FL) was performed either via median sternotomy (MST, 21 pts.) or via minimal-invasive technique via anterolateral thoracotomy and partial L-shape sternotomy (MIC, 18 pts.). All operations were performed beating heart with the use of the extracorporeal circulation (ECC) or completely off-pump.

All operations were performed electively. Patients with an INTERMACS level of 1 or 2 were excluded from this study.

Results: The Table shows the preoperative risk profile. Age, gender, EuroScore, previous sternotomy and INTERMACS level were identical between the groups. While the average operation time was similar (212 ± 31 vs. 193 ± 63 minute, p = 0.244; MIC vs. MST); the time of ECC could be reduced with the MIC technique significantly (19 ± 25 vs. 83 ± 33 minute, p < 0.0001). In addition 27.8% of the MIC implants were performed completely off-pump. This might the reasons for trends toward postoperative reduction on ICU stay (6.4 ± 9.4 vs. 9.4 ± 13.9 days, p = 0.437), rate of reintubation (12.5 vs. 19.0%, p = 0.472) and rethoracotomies (9.1 vs. 31.6%, p = 0.197).

Conclusion: The minimal-invasive LVAD-Implant technique reduced the time of the ECC significantly. This might lead to shorter ICU stay with reduced morbidity. Adverse event due to the MIC technique were not observed. Larger numbers are needed to gain significant benefits in long-term survival. However, especially in the older DT population the MIC technique has the advantage for faster recovery after LVAD implantation.

Table Preoperative demographics

	MIC	MST	p Value
Age, years	65.6 ± 6.8	67.5 ± 5.7	0.359
Gender, male	88.9%	81.0%	0.667
Previous cardiac operation	44.4%	28.6%	0.337
INTERMACS level	4.3 ± 1.1	3.6 ± 1.2	0.058
EuroScore I	9.7 ± 2.7	11.1 ± 3.6	0.0166
Ischemic cardiomyopathy	66.7%	81.0%	0.465

No conflict of interest has been declared by the author(s).