Outcomes of obese patients undergoing less invasive LVAD implantation.

BACKGROUND: Obesity and heart failure rates continue to rise, confronting heart failure centers with challenging left ventricular assist device (LVAD) implantations. Although less invasive approaches to implantation have been successfully implemented by many centers, this surgical approach has not yet been well evaluated in the obese population. Therefore, we sought to describe our experience with less invasive device implantation in this patient cohort. METHODS: All implants of centrifugal ventricular assist devices were retrospectively reviewed. Patients implanted with a less invasive approach via a left thoracotomy and upper hemisternotomy were included. Patients were stratified by body mass index (<30 vs ≥30 kg/m2 ). Perioperative and short-term outcomes were evaluated. RESULTS: Forty-two patients implanted with the less invasive approach (BMI <30: 27 vs. BMI ≥30 kg/m2 : 15) were identified. The obese cohort was significantly younger (58.5 vs 46.1 years, P = .022), while other preoperative demographics were similar. Postoperative mechanical ventilator time was longer in the obese cohort (22.9 vs 46.1 hour, P = .045). However, other perioperative and short-term outcomes were comparable. Wound dehiscence occurred in one obese patient. Six-month survival was also comparable between cohorts (96.3% vs 86.7%, P = .264). CONCLUSIONS: In this limited patient series, outcomes appear to be comparable in nonobese and obese patients undergoing less invasive LVAD implantation. Therefore, obesity should perhaps not be viewed as a lone contraindication to the application of this surgical approach.

Individualized Antithrombotic Therapy in Heartware HVAD Recipients.

There are no evidence-based guidelines for antithrombotic therapy in left ventricular assist device patients. We evaluated the efficacy of a multi-agent, test-guided protocol, which remained consistent throughout our use of the Heartware HVAD. Thrombelastography and platelet function analyzer (PFA)-100 guide antiplatelet titration. Goals are normal kaolin thrombelastography maximum amplitude and prolonged PFA-100. We analyzed incidence and rates of nonprocedural bleeding, stroke, and pump thrombosis for all 81 primary Heartware left ventricular assist devices implanted since 2011. For each event, we examined whether each test was within goal range. We also compared medication burden and dosage between patients with and without events. Pump thrombosis and hemorrhagic stroke each occurred in two patients (2.5%; 0.03 events/patient-year [EPPY]), and ischemic stroke in six (7.4%; 0.10 EPPY). Nonprocedural bleeding occurred 75 times in 34 patients (42%; 1.24 EPPY), primarily gastrointestinal (28%; 0.66 EPPY). Subtherapeutic international normalized ratio (INR) was the most common at thrombotic events; supratherapeutic partial thromboplastin time, international normalized ratio (INR), and PFA-adenosine diphosphate (ADP) were common at bleeding events. Medication burden and dosage were lower in patients with events than in stable patients. Protocol-guided antithrombotic therapy resulted in low rates of pump thrombosis and hemorrhagic stroke. Ischemic stroke and gastrointestinal bleeding rates were higher than in a comparable HVAD population. Optimization of our protocol to decrease its complexity and to reduce bleeding is underway.

Minimally Invasive Left Ventricular Assist Device Implantation: Implementation Early in a Surgical Career.

OBJECTIVE: Several centers have presented minimally invasive surgical approaches to centrifugal left ventricular assist device implantation. Although minimally invasive implantation has been successfully performed by experienced surgeons, at large implanting centers, it is unknown whether these techniques are widely adoptable. We evaluated the experience of a surgeon early in his career with conventional and minimally invasive approaches to device implantation. METHODS: All consecutive left ventricular assist device implantations by a single surgeon in the first year of practice (2015-2016) were retrospectively reviewed. Patients were stratified by standard approach, conventional full sternotomy versus a minimally invasive approach, left anterior thoracotomy and upper hemisternotomy. Demographics, perioperative variables, and short-term outcomes were compared using Wilcoxon rank-sum test. RESULTS: Thirteen patients were identified: six performed via the standard approach and seven performed via the minimally invasive approach. Preoperative demographics were comparable in both groups. However, there was significantly more preoperative right ventricle dysfunction in the minimally invasive group (P = 0.01). Although operative time was significantly longer in the minimally invasive cohort, there was a trend toward decreased cardiopulmonary bypass time. Six-month survival in both groups was 100%. CONCLUSIONS: Compared with conventional sternotomy, minimally invasive ventricular assist device implantation, performed by a surgeon in his first year of practice, had similar perioperative outcomes and excellent survival. Based on these data, minimally invasive implantation may be a feasible strategy for device implantation even early in a surgeon's career.