UPMC Heart and Vascular Institute Surgical Team Performs First Robotically-Assisted, Minimally Invasive Left Ventricular Assist Device Implantation

In December 2023, experts from the UPMC Heart and Vascular Institute performed the world's first robotically-assisted, minimally invasive implantation of a HeartMate 3™ left ventricular assist device (LVAD).

Collaborating on the case were Johannes Bonatti, MD, FETCS, professor of Cardiothoracic Surgery and director of Robotic Cardiac Surgery at the UPMC Heart and Vascular Institute, and David Kaczorowski, MD, associate professor of Cardiothoracic Surgery and surgical director of the Center for Advanced Heart Failure at the UPMC Heart and Vascular Institute. They worked in the operating room with a team of 15 other health care professionals, including anesthesia, scrub techs, perfusionists, and LVAD engineers.

LVAD Implantation – Why and When?

LVADs have become critical tools for managing advanced heart failure. LVADs, notably the HeartMate 3 – the latest model and currently only approved device on the market in the United States – have demonstrated substantial benefits in extending and improving the quality of life in patients with heart failure. LVADs are used to support a patient’s heart function either as bridge to heart transplantation while the patient waits for a suitable donor organ to become available, or as a destination therapy for long-term heart function support in individuals who are not candidates for a transplant but who may be able to tolerate the implantation and use of the device for many years.

“LVADs have been well established through use and rigorous clinical studies, for well-selected patients, to extend and greatly improve the quality of life for someone with heart failure,” says Dr. Kaczorowski. “LVAD technology is continually evolving and improving, which is one of the reasons our team was able to use a minimally invasive, robotically-assisted approach for the first time.”

Minimally Invasive Approaches to LVAD Implantation: Patient Benefits

As with minimally invasive and robotic surgical approaches in other disciplines, minimally invasive surgery, and the use of robotic assistance in cardiothoracic surgery can afford patients several significant benefits.

As Dr. Bonatti explains, these are things like faster healing and recovery times, reduced postsurgical pain, shorter stays in the CICU, and improvements in outcomes at the time of heart transplantation for those in which the LVAD is used as a bridge therapy. In the latter patient group, it is easier for the transplant surgeon to re-enter the chest and to remove the sick heart with the LVAD before the donor heart is implanted.

“Earlier versions of LVADs were too large for such approaches,” says Dr. Bonatti. “But advancements in the technology have made newer models like the HeartMate 3 amendable to minimally invasive surgical techniques.”

Dr. Kaczorowski explains that minimally invasive approaches to LVAD implantations, while not new, have other potential benefits, including reduced blood loss during surgery, and possibly lower incidences of right ventricular failure, which can be a complication post-LVAD implantation. However, more evidence and research need to accumulate before these benefits can be definitively determined.

About the Case and its Surgical Approach/Techniques

The case involved a patient that was unsuitable for an immediate heart transplantation, necessitating LVAD implantation as a bridge therapy.

The innovative surgical approach devised for this case combined Dr. Kaczorowski's experience with minimally invasive techniques for LVAD implantation with Dr. Bonatti's expertise in cardiothoracic robotic-assisted surgery to perform a first-of-its-kind procedure.

The minimally-invasive procedure involved multiple steps and approaches after the patient was put on cardiopulmonary bypass. First, Drs. Bonatti and Kaczorowski inserted the LVAD pump through a small thoracotomy on the left side and attached it to the left ventricle.

Next, a right-sided mini thoracotomy was performed. The outflow graft from the LVAD that connects to the patient’s ascending aorta via anastomosis was tunneled from the left side to right-sided mini thoracotomy with Drs. Kaczorowski and Bonatti assisting each other with direct visualization. The anastomosis was created using strong synthetic suture material, and the graft was sewn to the aorta using robotic instrumentation. Robotic assisted suturing is easier and more precise than what could be obtained using long minimally invasive instruments, according to Drs. Bonatti and Kaczorowski.

3D and HD cameras part of the robotic platform offer superb visualization of the anatomic structures and the surgical maneuvers.

“This approach using two separate thoracotomies allows us to forgo the typical need for a partial upper sternotomy with which the outflow graft anastomosis would traditionally be done,” explains Dr. Bonatti. “This has several downstream benefits, including reduced scarring to the sternum and safer reentry when the LVAD is removed as part of the future heart transplant process.”

Additionally with this approach, the outflow graft is nearly completely covered by pericardium. This again offers downstream benefits at the time of future transplantation because of how the pericardium protects the outflow graft on reentry. Also, the right atrium and ventricle are better protected from dilating, ensuring a more balanced cardiac output, preventing right-sided heart failure and other complications, optimizing LVAD function, and improvements in outcomes.

In the future, Drs. Kaczorowski and Bonatti believe that it is possible with the approach they have devised that the outflow graft anastomosis portion of the procedure could be transformed into a completely endoscopic approach, obviating the need for the right-sided mini thoracotomy.

“A lot of work and experimentation will be required before that aspect of the procedure is ready for an endoscopic-only approach,” says Dr. Kaczorowski, “But it is certainly well within the realm of possibility, and we are actively exploring this pathway.”

As LVAD technology continues to evolve, one hope is that they will become smaller, which will enable further reductions of the implantation invasiveness.

The future of LVAD implantation is likely to continue to move toward minimally invasive techniques coupled with the precision afforded by robotic assistance, but at the heart of the matter is the expertise, vision, and pioneering work of surgeons like Dr. Bonatti and Dr. Kaczorowski harnessing the latest technological advancements to make it a reality.