Saverio La Francesca

A Less Invasive Approach to Axial Flow Pump Insertion

BACKGROUND Implantation of a HeartMate II or a Jarvik 2000 FlowMaker left ventricular assist system (LVAS) usually involves a mid-line sternotomy and the use of cardiopulmonary bypass (CPB). In patients with numerous co-morbid conditions, however, surgical trauma may be minimized by implanting the LVAS via a minimally invasive approach, preferably without CPB. METHODS In 6 patients with end-stage heart failure and other serious co-morbidities, we implanted a HeartMate II (n = 3) or a Jarvik 2000 FlowMaker (n = 3) LVAS via a right mini-thoracotomy and a left sub-costal incision. Patients included 3 men and 3 women with a mean age of 41 years. In 3 cases, the LVAS was implanted without CPB. RESULTS After a mean follow-up period of 6 months, 5 patients are alive and well and on the transplant waiting list. Seven months after LVAS implantation, the remaining patient developed a hemorrhagic stroke necessitating Jarvik 2000 replacement with a new pump of the same type. CONCLUSIONS In this small series, the combined sub-costal and mini-thoracotomy incision proved safe and technically feasible. It may be useful for other LVAS candidates who have serious co-morbidities that preclude traditional implant operations.

Clinical experience with sternotomy versus subcostal approach for exchange of the HeartMate XVE to the HeartMate II ventricular assist device.

BACKGROUND Most patients undergoing destination therapy with a HeartMate XVE left ventricular assist device will eventually require pump exchange to continue long-term cardiac support. METHODS To determine whether left ventricular assist device exchange can be accomplished with low morbidity and mortality, we retrospectively reviewed the records of 14 patients who experienced pump malfunction and subsequently required replacement of their HeartMate XVE left ventricular assist devices with HeartMate II axial-flow pumps. We collected data regarding duration of support and reasons for pump failure, perioperative characteristics, and operative approach. RESULTS On average, patients were supported 473 +/- 233 days with HeartMate XVE pumps. Seven early patients required both subcostal and sternotomy incisions; 7 later patients had subcostal incisions only. Thirteen patients underwent successful exchange to the HeartMate II; 1 patient died in the operating room. Another patient died in the perioperative period (30-day mortality, 14% [2 of 14]). There were significant differences between the two groups. The patients who required only subcostal incisions had shorter operative times (187 versus 220 minutes; p = 0.04) and required fewer transfused blood products (packed red blood cells, 8.6 versus 28.7 units; p = 0.03; and fresh-frozen plasma, 12.4 versus 30.9 units; p = 0.04). Additionally, the patients with subcostal incisions had shorter postoperative intensive care unit stays (5.3 +/- 1.1 versus 8.4 +/- 3.1 days for redo sternotomy patients; p = 0.03). Of the survivors, average hospital stay was 22 +/- 14 days. Average long-term follow-up was 11.2 +/- 7.8 months; 71% (10 of 14) of patients are currently alive. CONCLUSIONS Exchange of a HeartMate XVE to a HeartMate II can be accomplished with relatively low morbidity and mortality through a subcostal approach.

Techniques and complications of TandemHeart ventricular assist device insertion during cardiac procedures.

Patients with heart failure and profound cardiogenic shock, who are unresponsive to vasopressors and intra-aortic balloon pump insertion, have few options except for mechanical cardiac support with a ventricular assist device. The TandemHeart is a new assist device that may be percutaneously or surgically inserted. We review techniques for percutaneous and intraoperative placement of the TandemHeart, including detailed descriptions of its insertion. Additionally, we present the most common complications associated with the percutaneous or operative approaches and suggest ways to avoid these complications. Whether placed percutaneously or surgically, the TandemHeart can provide adequate hemodynamic support for heart failure patients. If the device is placed by surgeons in the operating room, there must be strict adherence to protocols and de-airing techniques. Complications may occur with either insertion technique, so knowledge of the most common types of complications and their prevention is necessary.

Experience of sternal secondary closure by means of a titanium fixation system after transverse thoracosternotomy.

Sternal dehiscence is a common complication after transverse thoracosternotomy in patients undergoing bilateral sequential lung transplantation (BSLT). These patients can be treated with conservative therapy, but severe dehiscence requires surgical reapproximation and secondary closure of the sternum. Seventy-one cases of patients who underwent BSLT between January 2007 and May 2009 were reviewed retrospectively. Out of 71 patients, the sternum was intact in two cases due to the use of bilateral anterolateral thoracotomy, and a clamshell incision had been utilized in 69 patients. Four patients (6.8%) presented with persistent chest pain with severe sternal dehiscence diagnosed by chest X-ray and/or chest computed tomography, and underwent sternal reapproximation using the Synthes Titanium Sternal Fixation System for longitudinal sternal plating. All four patients had successful sternal realignment and resolution of their preoperative clinical symptoms. No perioperative or postoperative complications were observed. The Synthes Titanium Sternal Fixation System is an appropriate and effective method for internal fixation of the sternum when used for symptomatic severe sternal dehiscence after sequential BSLT via transverse thoracosternotomy.