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Axial to Centrifugal continuous flow LVAD pump exchange using minimally invasive technique
Amit Pawale, MD, FRCS (CTh), Dimosthenis Pandis, MD, PhD, Ariel Farkash, MD, PhD, Anelechi C. Anyanwu, MD, FRCS (CTh).
Mount Sinai Medical Center, New York, NY, USA.

Objective
Device infection with extensive soft-tissue abdominal wall destruction may complicate axial flow left ventricular assist device (AFLVAD) implants, and only curative option may be pump exchange. Replacement with similar device is liable to reinfection, as pump configuration is such that the new device may partly lie within infected tissue. We describe treatment of severe AFLVAD infection by minimally invasive exchange to an intrapericardial  centrifugal flow left ventricular assist device (CFLVAD).
Methods
A 53 year old male with an AFLVAD developed refractory device infection with multiple sinuses discharging pus via the abdominal wall, despite antibiotics and repeat surgical debridement. We decided to switch to a CFLVAD to allow abdominal wall healing.
We performed a fifth intercostal space left minithoracotomy and a vertical midline epigastric incision. Peripheral cardiopulmonary bypass was instituted. We clamped the outflow graft of AFLVAD through the epigastric incision. We then divided the device inflow via the minithoracotomy, and through the two incisions dissected and explanted the pump. The existing apical cuff was excised. A tunnel was dissected anterior to the right ventricle, connecting the two incisions, for later passage of the outflow graft. The CFLVAD was then implanted  in the apex and secured. The outflow graft was tunneled to the epigastric incision and anastomosed to the transected AFLVAD outflow graft. The driveline was exteriorized away from the infected abdomen.  LVAD support was initiated and CPB weaned. After the incisions were closed, we debrided the abdominal wall and placed a  drain in the abscess cavity.
Results
Patient had uneventful recovery. After six weeks, the abdomen had healed completely and antibiotics
had been stopped without recurrence of infection.
Conclusion
Axial to Centrifugal continuous flow LVAD pump exchange for extensive driveline/pocket infection is possible using non-sternotomy approach and may reduce the morbidity of what would otherwise be a very invasive reoperation.


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