Complete Sternal Sparing LVAD Implantation

Left ventricular assist device (LVAD) implantation has two approaches. Of the two, the right mini thoracotomy is the less invasive, as it is sternal sparing. This approach assists with chest stabilization, mobility, virgin tissues for bridge to transplant, and retained pericardium for the right heart support. The preferred lie of the outflow graft is also preferred via the mini thoracotomy. 

To start, pacemaker settings are investigated with EP colleagues prior to the procedure and made available for interrogation. Next, the clavicle is marked off, perform the standard sternal incision for sternotomy bailout, and perform a transthoracic ultrasound by surgeon to localize the apex of the heart given expected remodeling because of chronicity of heart failure. 

For the left thoracotomy, a 7-8 cm 5th intercostal incision is performed with care to consider preprocedure apical localization. The interspace is then exposed and a rib retractor place. Next, the interspace opening is extended further, which aids in interspace opening, allowing the surgeon to avoid transecting mid rib. 

Simultaneously, the right femoral vein is accessed with placement of a 5-6 Fr sheath, and then a right mini thoracotomy measuring 4–5cm incision is performed. The pectoralis is entered, the intercostal space is exposed, and a wet lap sponge is placed with lungs down to control and protect the lung. Here, the mammary artery and vein is located and transected following hemoclips. The lower cartilage is scored, and a sternal saw is used to disarticulate the third rib, keeping the second rib intact for preferred visualization. 

For both thoracotomies, a soft tissue retractor is ultimately placed, allowing for circumferential exposure, and a rib retractor is placed following this soft tissue retractor, allowing for additional exposure. 

At the left thoracotomy, the apex is then localized with digital imprint verified by 2 view TEE image guidance. When ideal location is found, four quadrant pledgeted sutures are placed at the diameter of the LVAD ring prior to parachuting the ring in place and securing  it. Additional circumferential sutures are placed as well, equally spaced without entering the heart. When this is found to be hemostatic, BioGlue is placed as well. 

Then, at the right thoracotomy, the right the pericardium is opened cranial and caudal above the aorta. Three pairs of sutures are placed along the length of the pericardium, both left and right. After this, the edges of the right pericardium are pulled toward the surgeon through the intercostal, which pulls the heart laterally, aiding in visualization of the aorta to the thoracotomy incision. Then, the left pericardial sutures are placed to the soft retractor at the incision, which further elevates the ascending aorta. 

The right femoral vein is then cannulated with TEE guidance on bicaval view, as well percutaneous placement of an ascending aortic cannulation simultaneously. 

Next, the outflow graft is marked at 12cm and 14cm and then introduced first through the left thoracotomy and tunneled lateral the right ventricle to the ascending aorta. A beveled resection is performed between both marked distances and a partial clamp is placed on the ascending aorta with care to avoid any transaortic ventricular assist devices, should one be present. The blood pressure is reduced and monitored closely during placement of a partial cross clamp, and an incision is made anterolateral on the ascending aorta with multiple aortic punch. Anastomosis of the outflow graft is then completed, and partial clamp is kept in place with BioGlue placed at anastomosis. Next, a DeBakey clamp is placed across distal tubing, and a partial clamp is released to reveal hemostasis of the anastomosis. 

At the left thoracotomy, CO2 is then placed at the medial end of the incision, facing the ring. Additional drop suckers are brought to the site in preparation to return blood to the field. Next, an apical coring device is introduced. Following core, the heart is emptied, drop suckers are placed through the apex, and the LVAD placed to follow. 

Two Blake chest tubes are placed at the left thoracotomy site, one being mediastinal near the aortic anastomosis and the other being left pleural near the LVAD. Then one chest tube is placed on the right side as well prior to the closure of right mini thoracotomy. 

Next, two 2-0 Vicryl sutures are placed through the upper and lower ribs of either thoracotomy site, which approximates the position of the lower ribs, preventing a lung hernia. Then, the mammary vessels are monitored closely to avoid injury during the maneuver. Finally, the incisions are closed in several layers. 

References

1. Louis C, Ayers B, Barrus B, Prasad S, Alexis JD, Bernstein W, Cheyne C, Gosev I. HeartMate 3 pump exchange via sternal-sparing bilateral minithoracotomies. J Card Surg. 2020 Apr;35(4):901-903. doi: 10.1111/jocs.14476. Epub 2020 Feb 25. PMID: 32097497.
2. Wood KL, Ayers BC, Sagebin F, Vidula H, Thomas S, Alexis JD, Barrus B, Knight P, Prasad S, Gosev I. Complete Sternal-Sparing HeartMate 3 Implantation: A Case Series of 10 Consecutive Patients. Ann Thorac Surg. 2019 Apr;107(4):1160-1165. doi: 10.1016/j.athoracsur.2018.10.005. Epub 2018 Nov 13. PMID: 30444989.
3. Gosev I, Wood K, Ayers B, Barrus B, Knight P, Alexis JD, Vidula H, Lander H, Wyrobek J, Cheyne C, Goldenberg I, McNitt S, Prasad S. Implantation of a fully magnetically levitated left ventricular assist device using a sternal-sparing surgical technique. J Heart Lung Transplant. 2020 Jan;39(1):37-44. doi: 10.1016/j.healun.2019.09.012. Epub 2019 Sep 25. PMID: 31636043.
4. Ayers BC, Bjelic M, Wood K, Sheen S, Morrison E, Prasad S, Gosev I. Complete sternal-sparing left ventricular assist device implantation is associated with improved postoperative mobility. Interact Cardiovasc Thorac Surg. 2021 May 27;32(6):878-881. doi: 10.1093/icvts/ivab017. PMID: 33537714; PMCID: PMC8691578.
5. Lindenmuth DM, Chase K, Cheyne C, Wyrobek J, Bjelic M, Ayers B, Barrus B, Vanvoorhis T, Mckinley E, Falvey J, Barney B, Fingerut L, Sitler B, Kumar N, Akwaa F, Paic F, Vidula H, Alexis JD, Gosev I. Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device. J Card Fail. 2021 Nov;27(11):1195-1202. doi: 10.1016/j.cardfail.2021.05.006. Epub 2021 May 26. PMID: 34048920.

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