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Left Ventricle Assist Device minimally invasive implantation: the evolution of surgical technique in a single centre experience
Jonida Bejko, Alvise Guariento, Marina Comisso, Massimiliano Carrozzini, Maurizio Rubino, Vincenzo Tarzia, Gino Gerosa, Tomaso Bottio.
Padua University, Padova, Italy.

OBJECTIVE: Evaluate our surgical experience with continuous flow left-ventricular-assist-devices (LVAD), from the original full-thoracotomy-approach to less invasive surgical strategies comprehending mini-sternotomy and/or mini-thoracotomies. We analyze the evolution of our LVAD surgical experience.
METHODS: We enrolled patients undergoing surgical implantation of one of the two LVAD types used in our centre (both are small, intra-pericardially positioned, continuous-flow-centrifugal), to reduce possible bias related to the device. Out of a total of 93 LVADs implanted in our centre, we retrospectively reviewed 52 (55.9%) who received the specific LVAD examined from December 2008 to November 2015. In this analysis we focused on the surgical implantation technique. Most of the patients (63.5%) were affected of end-stage heart failure due to post-ischemia or dilative cardiomyopathy, receiving the LVAD in INTERMACS class score of I-II. Mean age, left ventricular ejection fraction and New York Heart Association class were 59.9 years, 19.23% and 3.77, respectively.
RESULTS: The implantation of LVAD was performed via full left-thoracotomy in 17 patients (32.69%), full-sternotomy in 4 patients (7.69%) whilst it was conducted throughout a mini-invasive procedure in the remaining 31 patients (59.6%). Mini-invasive approaches were combined upper mini-sternotomy with left mini-thoracotomy (9 patients, 17.3%) and combined bi-mini-thoracotomy (22 patients, 42.3%). The most common postoperative complications were acute right ventricular failure (RVF - 21.15%) and revision for bleeding (RB - 32.69%). RB was significantly related to both full-sternotomy (75% of the sternotomies) and full-thoracotomy (47% of the thoracotomies) with a total of 52.4% versus 22.58% of incidence for the mini-invasive approaches (p 0.026). Regarding the RVF, it was recorded in 50% of the sternotomies and 11.7% of the thoracotomies for a total of 19%, versus 22.6% of incidence in the mini-invasive approach (p 0.76). The most frequent cause of death was stroke (ischemic or hemorrhagic) (11.5%). 9 patients were successfully transplanted.
CONCLUSIONS: Satisfactory mid-term survival in severely compromised patients was recorded in our series. Trend versus a decrease in post-operative bleeding, mechanical ventilation and additionally reduced post-operative in-hospital stay was observed during time-technique evolution towards mini-invasive surgical technique while regarding RVF, the mini-invasive approach is not diriment for the LVAD model analyzed.

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