Less Invasive Reoperative Ventricular Assist Device Insertion Reduces Right Ventricular Failure for Patients with History of Coronary Artery Bypass Grafting
Presented During:
Friday, September 20, 2024: 5:00PM - 6:30PM
Omni King Edward Hotel
Abstract No:
10108
Submission Type:
Abstract Submission
Authors:
Junichi Shimamura (1), Sooyun Tavolacci (1), Elliot Levine (1), David Spielvogel (1), Masashi Kai (2), Suguru Ohira (1)
Institutions:
(1) Westchester Medical Center, Valhalla, NY, (2) Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Submitting Author:
Junichi Shimamura
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Westchester Medical Center
Westchester Medical Center
Co-Author(s):
Sooyun Tavolacci
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Westchester Medical Center
Westchester Medical Center
Elliot Levine
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Westchester Medical Center
Westchester Medical Center
*David Spielvogel
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Westchester Medical Center
Westchester Medical Center
Masashi Kai
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Beth Israel Deaconess Medical Center, Harvard Medical School
Beth Israel Deaconess Medical Center, Harvard Medical School
Suguru Ohira
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Westchester Medical Center
Westchester Medical Center
Presenting Author:
Junichi Shimamura
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Westchester Medical Center
Westchester Medical Center
Abstract:
Objective: Reoperation for durable left ventricular assist device (LVAD) insertion after coronary artery bypass grafting (CABG) is challenging due to potential injury to bypass grafts, great vessels, or the right ventricle (RV). We sought to analyze if less invasive LVAD implantation may improve outcome due to limited dissection around the heart which can reduce bleeding, graft injury, or RV failure.
Method: From Mar. 2012 to May. 2024, 29 patients with history of CABG received reoperative LVAD; 16 patients had redo full sternotomy (Group FS) and 13 patients had less invasive approach (Group LI). Since May 2019, LI approach has been used which includes: an inverted-T upper hemisternotomy at the level of the 2nd or 3rd intercostal space, dissection along the chest wall into the left pleural space, anastomosis of inflow cuff incorporating pericardium via a left thoracotomy in the 5th or 6th intercostal space, routing the outflow graft through the left pleural space, and outflow graft anastomosis to the ascending aorta. Either ascending aorta or axillary artery was used for arterial return and femoral vein was percutaneously cannulated.
Results:
The median age was 68 years in Group FS and 66 years in Group LI (P=0.81), respectively. The median duration from the last cardiac surgery was 118 [29, 192] months. Six patients had preoperative veno-arterial extracorporeal membrane oxygenation support (Group FS, 18.8% [N=3] vs. Group LI, 23.1% [N=3], P=0.56). Heartmate 2 was exclusively used in Group FS (Group FS, 56.3% [N=3] vs. Group LI, 0%), while HeartWare was predominantly used in group LI (FS, 31.3%, [N=5] vs. LI, 53.8% [N=7]. Heartmate3 was used in 6 patients. Left internal mammary artery graft was patent in 25 patients (86.0%). None of patients had injury of bypass graft. Concomitant procedure was performed in 5 patients in FS group (aortic valve, N=3, and tricuspid valve, N=2). In isolated LVAD implantation, cardiopulmonary bypass time was comparable between groups (FS, 92 [68, 96] min vs. LI, 82 [61, 96] min, P=0.33). The incidence of severe RV failure requiring mechanical support was less in LI groups (FS: 43.8% [N=7] vs. 0%, P=0.01), as was hospital mortality (FS: 31.3% [N=5] vs. LI, 9.1% [N=1], P=0.18). The rate of tracheostomy (FS: 62.5% [N=10] vs. 23.1 % [N=3], P=0.06) and hemodialysis (FS: 37.5% [N=6] vs. 7.7 % [N=1], P=0.18) were numerically higher in FS group. One-year estimated survival was not significantly different (FS: 68.8+\-11.6% vs. LI, 83.1 8+\-11.0 %, P=0.97).
Conclusions: Less invasive reoperative LVAD insertion may have a potential to reduce RV failure and hospital mortality in patients with history of CABG compared to FS approach, and can improve overall outcomes.
Method: From Mar. 2012 to May. 2024, 29 patients with history of CABG received reoperative LVAD; 16 patients had redo full sternotomy (Group FS) and 13 patients had less invasive approach (Group LI). Since May 2019, LI approach has been used which includes: an inverted-T upper hemisternotomy at the level of the 2nd or 3rd intercostal space, dissection along the chest wall into the left pleural space, anastomosis of inflow cuff incorporating pericardium via a left thoracotomy in the 5th or 6th intercostal space, routing the outflow graft through the left pleural space, and outflow graft anastomosis to the ascending aorta. Either ascending aorta or axillary artery was used for arterial return and femoral vein was percutaneously cannulated.
Results:
The median age was 68 years in Group FS and 66 years in Group LI (P=0.81), respectively. The median duration from the last cardiac surgery was 118 [29, 192] months. Six patients had preoperative veno-arterial extracorporeal membrane oxygenation support (Group FS, 18.8% [N=3] vs. Group LI, 23.1% [N=3], P=0.56). Heartmate 2 was exclusively used in Group FS (Group FS, 56.3% [N=3] vs. Group LI, 0%), while HeartWare was predominantly used in group LI (FS, 31.3%, [N=5] vs. LI, 53.8% [N=7]. Heartmate3 was used in 6 patients. Left internal mammary artery graft was patent in 25 patients (86.0%). None of patients had injury of bypass graft. Concomitant procedure was performed in 5 patients in FS group (aortic valve, N=3, and tricuspid valve, N=2). In isolated LVAD implantation, cardiopulmonary bypass time was comparable between groups (FS, 92 [68, 96] min vs. LI, 82 [61, 96] min, P=0.33). The incidence of severe RV failure requiring mechanical support was less in LI groups (FS: 43.8% [N=7] vs. 0%, P=0.01), as was hospital mortality (FS: 31.3% [N=5] vs. LI, 9.1% [N=1], P=0.18). The rate of tracheostomy (FS: 62.5% [N=10] vs. 23.1 % [N=3], P=0.06) and hemodialysis (FS: 37.5% [N=6] vs. 7.7 % [N=1], P=0.18) were numerically higher in FS group. One-year estimated survival was not significantly different (FS: 68.8+\-11.6% vs. LI, 83.1 8+\-11.0 %, P=0.97).
Conclusions: Less invasive reoperative LVAD insertion may have a potential to reduce RV failure and hospital mortality in patients with history of CABG compared to FS approach, and can improve overall outcomes.
Mechanical Support and Thoracic Transplantation Summit:
ECMO/Mechanical Support
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