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Canadian Journal of Cardiology

STERNUM-SPARING LEFT VENTRICULAR ASSIST DEVICE INSERTION REDUCES BLOOD LOSS AND PERIOPERATIVE TRANSFUSIONS: INITIAL CANADIAN EXPERIENCE

      BACKGROUND

      In end-stage heart failure, left ventricular assist devices (LVADs) improve survival and quality of life as destination therapy or bridge to transplantation. This sternum-sparing approach avoids the complications of sternotomy and the risk of sternal re-entry for transplantation. There may also be benefits associated with less blood loss and transfusion. Though less-invasive hemisternotomy approaches are well studied, there is a paucity of data in the literature for sternum-sparing BMT. Our center has one of Canada's largest experiences with the BMT approach. Herein, we compared LVAD implantation via BMT with patients who received full median sternotomy or hemisternotomy.

      METHODS AND RESULTS

      LVAD implantation via bilateral minthoracotomy (image) uses a left anterolateral minithoracotomy for device implantation and right anterior minithoracotomy for aortic anastomosis of the outflow graft. Pericardial tunnelling of the outflow graft retains the pericardium as a barrier between the sternum and heart. A single centre retrospective review was performed at the Foothills Medical Centre (Calgary, Canada) for patients undergoing LVAD insertion from 2012 to 2019. Data was collected from chart review and the Metavision Database. Patients received either BMT (n=11) or sternotomy (full median sternotomy or upper hemisternotomy with left thoracotomy; FS/HS; n=41). Continuous and categorical variables were analyzed by Wilcoxon Rank Sum and Chi-Squared tests respectively. The accompanying table shows patient demographics and perioperative outcomes. Patients receiving BMT were younger and there were no other significant differences in group characteristics related to INTERMACS classification, etiology of heart failure and cardiovascular risk factors. BMT had similar cardiopulmonary bypass times and cross-clamp times to the FS/HS group. There were no differences in stroke or mortality. BMT reduced total intraoperative and CVICU transfusions of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets when compared to the full/hemisternotomy group. Additionally, BMT had reduced chest tube outputs in the first 12 hours after LVAD implantation.

      CONCLUSION

      Outcomes suggest sternum-sparing LVAD implantation is a safe alternative to sternotomy with less post-operative blood loss and transfusion in the early Postoperative period. Less transfusion is particularly valuable in this patient population to reduce antigen-related sensitization prior to transplantation. Additional study is needed to assess potential benefits of this approach for post-operative mobility and patient-reported quality of life metrics.
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