Abstract 21162: Subcostal Exchange of Left Ventricular Assist Devices - A Novel Approach
Introduction: A limitation of long-term left ventricular assist device(LVAD) support is the need for device exchange, with risks of a redo-sternotomy. We describe LVAD exchange through a novel, less invasive subcostal approach.
Hypothesis: LVAD exchange can be performed safely through a less invasive approach.
Methods: A retrospective review of a prospectively collected institutional LVAD database for Heartmate XVE(HM1) and HeartmateII(HM2) LVAD patients undergoing device exchange via a subcostal incision(6/2000–7/2009). LVADs are accessed via a left subcostal incision. Femoral vessels are used for cardiopulmonary bypass(CPB) if necessary. Exchange is performed by connecting the original outflow graft and inflow connector elbow to the new pump. Conversion from HM1 to HM2 requires outflow graft-to-graft anastomosis and exchange of the entire inflow cannula. Demographic and operative data, indications for exchange, complications, and survival were reviewed.
Results: 14 patients had device exchange via a subcostal approach. CPB was required in 12/14. Mean support duration prior to exchange was 520±210d, and was longer for HM2 devices(589vs.348d,p=0.05). 6(43%) devices were replaced for mechanical failure; 4(29%) for electrical failure; and 4(29%) for infection. 12 devices were replaced with HM2's and 2 with HM1's. Median duration of mechanical ventilation after exchange was 34.5hrs (Interquartile Range (IQR):15–90). Median intensive care unit length of stay was 4d(IQR:3–8). Average intraoperative transfusions were: 6.5(±4.3) units packed red blood cells; 4.5(±3.1) units fresh frozen plasma; 0.9(±0.8) units of platelets. There were no intra-operative or peri-operative deaths. At the end of follow-up, 1(7%) patient received a heart transplant, 6(43%) died, and 7(50%) continued on LVAD support.
Conclusions: Device failure is an increasingly common complication of long term LVAD support. Access via a subcostal incision for device exchange is a useful and novel alternative to median sternotomy, and can be performed without additional morbidity or mortality.
- © 2010 by American Heart Association, Inc.