Minimally Invasive LVAD Implantation for Durable Ventricular Support

Written by David Kaczorowski, MD.

For the last 30 years, UPMC has been at the forefront of ventricular-assist technology to support patients with failing hearts. Minimally invasive placement of left-ventricular assist devices (LVADs) is a recent advancement in the field that has been adopted by the surgeons who specialize in heart transplant and ventricular support within the Division of Adult Cardiac Surgery, part of the UPMC Department of Cardiothoracic Surgery. Minimally invasive LVAD placement is easier for patients to recover from and improves perioperative outcomes. David Kaczorowski, MD, specializes in minimally invasive LVAD placement and has studied clinical outcomes extensively after this procedure.

UPMC maintains one of the largest mechanical circulatory support programs in the United States and was one of the earliest adopters of left-ventricular assist device (LVAD) technology. In 1990, heart specialists at UPMC were the first in the nation to discharge a patient on ventricular assist device (VAD) support, and in 2004, UPMC was one of the first centers to implant an LVAD intended to provide durable circulatory support rather than simply bridge the patient until a heart transplant could be performed. To date, UPMC experts have placed more than 1,300 VADs to provide circulatory support to patients with heart failure. The LVAD program at UPMC is well established with experienced specialists including surgeons, heart failure cardiologists, engineers, advanced practice providers, and critical care medicine physicians. This level of expertise is critical for patient care. Depending on the patient’s clinical condition, a VAD may be placed as a bridge to a heart transplant or may be considered destination therapy or a bridge to recovery, providing support while allowing the heart to begin functioning at levels capable of maintaining the systemic circulation again. Many patients can return to the normal activities of daily life with durable mechanical circulatory support from a VAD.

In the past, open surgery, usually a full sternotomy, was necessary to place an LVAD due to the size of the devices. As LVAD technology advanced, LVADs became smaller, which paved the way for less invasive approaches for insertion. Design improvements have also lowered complication rates and improved survival.

Minimally invasive VAD placement procedures are performed in the absence of a complete sternotomy. To place an LVAD using a minimally invasive approach, we typically use two small incisions — a small upper sternotomy to expose the aorta and an anterolateral minithoracotomy on the left side of the chest to expose the apex of the left ventricle. We insert the LVAD through the minithoracotomy and attach it to the left ventricular apex via a sewing ring that is part of the device (Figure 1). The patient is then placed on cardiopulmonary bypass (CPB). We take a core of the myocardium and insert the LVAD into the left ventricle. We tunnel the vascular outflow graft to the upper sternotomy site and suture it onto the aorta through the small sternotomy that allows access to the aorta. Total operative time for minimally invasive LVAD placement may be longer than that needed for LVAD insertion via sternotomy, but the time the patient spends on CPB time is often shorter.^1,2

Placing the sewing ring at the apex of the left ventricle during minimally invasive LVAD implantation.

In some patients, LVAD insertion can be performed without CPB, although rapid initiation of CPB should be anticipated if difficulties arise.^3,4

There are fewer contraindications to minimally invasive LVAD placement than one might think. This minimally invasive approach can be used in select patients with prior cardiac surgery or who require concomitant procedures and in patients who require mechanical circulatory support preoperatively.^4,5 A significant degree of lateral adiposity or soft tissue may be contraindicative for minimally invasive LVAD insertion, however, and if a patient requires sternotomy for a concomitant procedure, it should be used instead of LVAD placement. I use the minimally invasive approach as my standard approach and reserve the open approach for special circumstances.

Minimally invasive LVAD placement is associated with low rates of conversion to open surgery and low perioperative mortality. Patients who undergo minimally invasive LVAD insertion have lower transfusion requirements, shorter hospital stays, and fewer reoperations for bleeding complications than patients with LVAD insertion via sternotomy.^2,6,7 Placing the LVAD using two small incisions also reduces the incidence of temporary right ventricular dysfunction after surgery. Right ventricular dysfunction is a known complication after LVAD placement using conventional sternotomy and may result from alterations in the geometry of the right ventricle caused by opening the pericardium or by right ventricular compression during sternotomy. These are largely avoided using the minimally invasive approach. When we compared 37 patients who underwent minimally invasive LVAD placement with 46 patients who underwent sternotomy for LVAD placement, the minimally invasive approach lowered the incidence of severe right ventricular failure after placement (16% vs. 39%, p=0.030) and consequently reduced the need for temporary right ventricular support (3% vs. 26%, p=0.005).¹ 

LVADs often serve as a bridge to a heart transplant. Minimally invasive placement of the LVAD facilitates several aspects of the subsequent heart transplant procedure, and patients who undergo heart transplant after bridging with an LVAD see benefits from the minimally invasive LVAD placement procedure during and after their heart transplant surgery. When we compared heart transplant in patients with minimally invasive LVAD placement or LVAD placement via sternotomy, it was easier to perform the sternotomy and do the transplant operation in patients with an LVAD placed using the two-incision, minimally invasive approach. This was attributed to fewer adhesions, less scarring, and the presence of a largely unopened pericardium. The patients with minimally invasive LVAD insertion had fewer blood transfusion requirements during the subsequent heart transplant surgery and a shorter hospital length of stay.⁸

Despite advances and documented successful outcomes, durable ventricular support is not the most appropriate support option for every patient. Many strategies are used at UPMC for temporary support of patients who present in acute heart failure or cardiogenic shock. Temporary VADs, such as the Impella® and TandemHeart® devices, or veno-arterial extracorporeal membrane oxygenation (ECMO) can be instituted using minimally invasive access or entirely percutaneously to support patients as needed. Surgeons in the Department of Cardiothoracic Surgery at UPMC have the expertise to evaluate which options are best suited for each patient. Importantly, due to the strong collaboration of experts from multiple disciplines, each patient treated at UPMC can get the care they need to minimize complications, recover, and return to daily life. Minimally invasive LVAD implantation is one way that the cardiac surgeons at UPMC are improving outcomes and providing quality care for patients with heart failure.

References

1. Pasrija C, Sawan MA, Sorensen E, Voorhees H, Shah A, Strauss E, et al. Less invasive left ventricular assist device implantation may reduce right ventricular failure. Interact Cardiovasc Thorac Surg. 2019;29(4):592-8.

2. Pasrija C, Sawan MA, Sorensen E, Voorhees HJ, Shah A, Wang L, et al. Less Invasive Approach to Left Ventricular Assist Device Implantation May Improve Survival in
High-Risk Patients. Innovations (Phila). 2020;15(3):243-50.

3. Shaffer A, Cogswell R, John R. Future developments in left ventricular assist device therapy. J Thorac Cardiovasc Surg. 2021;162(2):605-11.

4. Schmitto JD, Mariani S, Abicht TO, Couper GS, Danter MR, Itoh A, et al. Expert Consensus Paper: Lateral Thoracotomy for Centrifugal Ventricular Assist Device Implant. Ann Thorac Surg. 2021;112(5):1687-97.

5. Ricklefs M, Hanke JS, Dogan G, Napp LC, Feldmann C, Haverich A, et al. Less Invasive Surgical Approaches for Left Ventricular Assist Device Implantation. Semin Thorac Cardiovasc Surg. 2018;30(1):1

6. Da Silva JP, Viegas M, Castro-Medina M, Da Fonseca Da Silva L. The Da Silva cone operation after the Starnes procedure for Ebstein’s anomaly: New surgical strategy and initial results. JTCVS Tech. 2020;3:281-3.

7. Lopes LM, Bezerra RF, da Silva JP, da Fonseca da Silva L. Critical Ebstein’s anomaly with circular shunt: from successful fetal therapy with non-steroidal anti-inflammatory drugs to biventricular repair using Da Silva cone technique. Cardiol Young. 2021;31(6):1039-42.