Less Invasive HeartMate 3 Left Ventricular Assist Device Implantation under Deep Hypothermic Circulatory Arrest for Severely Calcified Aorta

Abstract

Introduction Left ventricular assist devices (LVADs) such as the HeartMate 3 (HM3) are becoming more frequently implanted in those with end-stage heart failure. We present one such patient with prior sternotomies and severely calcified ascending aorta in whom we planned a less invasive LVAD implantation via redo hemi-sternotomy and left thoracotomy with short-term deep hypothermic circulatory arrest (DHCA) to avoid cross-clamping of the aorta. Case Report A 70 year old male with history of two prior cardiac surgeries and heart failure presented in cardiogenic shock requiring temporary mechanical support with Impella CP. He continued to require increasing doses of inotropes and pressors; therefore, he was approved for high risk LVAD placement. A preoperative 4D CT scan revealed severely calcified ascending aorta with only a small area of focal sparing. First, a left anterior thoracotomy in the fifth intercostal space and redo upper hemi-sternotomy was performed. The LVAD outflow graft was positioned through the thoracotomy and brought up to the ascending aorta via the right pleural space, which was opened from the hemi-sternotomy. After initiation of cardiopulmonary bypass, the patient was cooled to 28°C with selective antegrade cerebral perfusion via the right axillary artery and systemic perfusion was temporarily arrested. DHCA was achieved. The LVAD outflow graft was then anastomosed to the aorta after which circulation was restarted and the patient rewarmed. The HM3 LVAD was then implanted in the LV apex and the rest of the operation was completed successfully. Summary Placing an LVAD via thoracotomy has theoretical advantages over a median sternotomy. Surgical trauma is minimized leading to less postoperative bleeding, improved maintenance of the chest stability, earlier recovery, and less cost. Additionally, there might be a reduction in post-operative right heart failure since the pericardium remains intact. Data from the LATERAL study and ELEVATE registry support the safety of this approach. While data support the safety of DHCA in other aortic arch procedures, there are only two case reports of DHCA for LVAD implantation. Our unique case validates the safety of LVAD implantation via thoracotomy and highlights the use of preoperative CT as well as DHCA in placement of an LVAD in a patient with severely calcified ascending aorta.