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Left Lateral Thoracotomy for Centrifugal Continuous-Flow Left Ventricular Assist Device Placement

An Analysis from the Mechanical Circulatory Support Research Network

Maltais, Simon*; Anwer, Lucman A.*,†; Tchantchaleishvili, Vakhtang*; Haglund, Nicholas A.§,¶; Dunlay, Shannon M.*; Aaronson, Keith D.; Pagani, Francis D.; Cowger, Jennifer#; Salerno, Christopher T.#; Shah, Palak#; Khalpey, Zain**; Schmitto, Jan††; Stulak, John M.*

doi: 10.1097/MAT.0000000000000714
Adult Circulatory Support

Continuous-flow left ventricular assist devices (CF-LVADs) have revolutionized the management of patients with advanced heart failure. Alternative implant strategies are increasingly used for device placement. We reviewed our experience from the Mechanical Circulatory Support Research Network registry with the HeartWare centrifugal CF-LVAD (HVAD). From May 2004 to August 2015, 1,150 patients underwent primary CF-LVAD implantation at our institutions. Within this group, a total of 283 patients (25%) were implanted with the HVAD. A minimally invasive left lateral thoracotomy (MILT) implant strategy was used in 53 patients (20%), of which 22 (42%) were implanted off-pump. Median age at implant was 59 years and 183 patients (65%) were implanted as bridge-to-transplantation. Follow-up was 100% complete for a total of 302 patient-years of support. In-hospital mortality was 4.9% (14 patients), and was comparable between the conventional sternotomy (CS) and MILT cohorts (p = 0.15). Patients in the MILT cohort had a shorter median length of stay (p < 0.01) and had a lower incidence of postimplant pump thrombus (p = 0.02). Cumulative survival at the end of follow-up reached 84%, and was comparable between the two groups (p = 0.298). Multivariate analysis identified preoperative bilirubin level as the only independent predictor of survival. Surgical technique had no impact on survival. In this large, multicenter experience, data demonstrate excellent survival and adverse event profiles for patients supported with the HVAD technology, regardless of surgical implant technique. With constant advancements in device technology along with our increasing clinical experience with the newer techniques, minimally invasive LVAD implantation continues to evolve as a valuable alternative to CS in selected patients.

From the *Mayo Clinic College of Medicine, Rochester, Minnesota

Department of General Surgery, University of Illinois at Chicago/MGH, Illinois

§Heart Failure Center, University of Kansas Health System, Kansas City, Kansas

Vanderbilt Heart and Vascular Institute, Nashville, Tennessee

Department of Cardiothoracic Surgery, University of Michigan Health System, Ann Arbor, Michigan

#St. Vincent’s Hospital, Indianapolis, Indiana

**Department of Cardiothoracic Surgery, University of Arizona, Tucson, Arizona

††Hannover Medical School, Hannover, Germany.

Submitted for consideration May 2017; accepted for publication in revised form October 2017.

Disclosure: Dr. Maltais is a consultant for ClearFlow, and Doctors Cowger and Maltais receive research funding from HeartWare, Inc. The University of Michigan has a research contract with HeartWare and receives research money from the NHLBI as well. Dr. Dunlay receives funding from both the NHLBI and the Patient-Centered Outcomes Research Institute (PCORI).

Correspondence: Dr. Simon Maltais, MD, PhD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email:

Copyright © 2018 by the American Society for Artificial Internal Organs