LVAD replacement approach leads to better outcomes

Surgeons using a nonsternotomy approach to replace continuous flow left ventricular assist devices (LVADs) found patients had better survival, according to a study published online Dec. 10 in Annals of Thoracic Surgery.

The research team led by Matthew A. Schechter, MD, from the Duke University Medical Center in Durham, N.C., reviewed consecutive implantations from 2005 through 2013 to derive their patient sample. They found 42 device replacement surgeries, 20 using reoperative sternotomy and 22 using nonsternotomy approaches. The devices involved in the procedures were HeartMate II (Thoratec) and HeartWare (HeartWare).

Patients within whom reoperative sternotomy was performed tended to have longer bypass procedures (129 vs. 42 minutes) and mechanical ventilation times (43.7 vs. 14.3 hours) and more frequently had concurrent cardiac procedures (11 vs. 1). Patients who underwent replacement via nonsternotomy had fewer transfusions, shorter hospital stays and experienced less right ventricular dysfunction.

Schechter et al found nonsternotomy replacements all survived through 90 days, while survival at 90 days was closer to 79 percent for patients who experienced reoperative sternotomy. No strokes or right ventricular dysfunction occurred among patients in the nonsternotomy group. Meanwhile, 26.3 percent of patients who underwent reoperative sternotomy had right ventricular dysfunction and 5 percent experienced a stroke.

They found nonsternotomy a safe and effective alternative to reoperative sternotomy. They suggested that as procedures and technology evolve, more concurrent procedures may be able to be performed via nonsternotomy.

Meanwhile, they wrote, “given the favorable outcomes with the NS [nonsternotomy] approach, our practice has become more conservative regarding addressing concurrent AI [aortic insufficiency] or TR [tricuspid regurgitation] at the time of replacement.”

Schechter et al recommended nonsternotomy approach for replacement of LVADs whenever possible.