Heartmate 3 Implant Through The Left Thoracotomy And Upper Hemi-sternotomy In The Presence Of Subcutaneous Icd
Kunal Kotkar, MD, Muhammad F. Masood, MD, Tomohiro Nakajima, MD, Ralph J. Damiano, Jr., MD, Akinobu Itoh, MD.
Washington University School of Medicine, Saint Louis, MO, USA.
OBJECTIVE: HeartMate3 Ventricular Assist Device is recently approved by FDA for bridge to transplant and the standard surgical approach is full-sternotomy. Considering the smaller device size, left thoracotomy for LV apex VAD implant plus upper hemi-sternotomy or small right thoracotomy for outflow graft anastomosis to the aorta may provide faster recovery and better outcome. This video presents the entire technical aspects of thoracotomy + upper hemi-sternotomy HeartMate3 Implant for a patient who has subcutaneous internal cardiac defibrillator.
METHODS: A 44 year-old male (182cm 110kg, Blood type O) was presented with STEMI of the diagonal artery after 2 year history of non-ischemic congestive heart failure in NYHA class IV. He previously received subcutaneous implantable cardioverter/defibrillator with the wire located along the 6th rib. His pulmonary artery pressure was 52/36(42) mmHg, right atrial pressure was 14mmHg with cardiac index of 1.6L/m2/min, pulmonary vascular resistance was 1.6 wood units with pulmonary artery pulsatility index of 1.3. Because of his recent smoking history and inotropic dependence, he was scheduled for LVAD implant as bridge to transplant. The video shows the surgical approach through 6th intercostal space under the ICD wire, and right upper hemi-sternotomy.
RESULTS: The procedure was safely performed with cardiopulmonary bypass time was 33min. He was admitted to the ICU postoperatively with 5,000 rpm on HeartMate3 with 0.1 mcg/kg/min of epinephrine. He was extubated on POD 1, chest tubes were removed by POD 5. He continued to have diureses for the RV failure and warfarin titration for device anticoagulation. He was discharged home on POD 18th.
CONCLUSIONS: The left thoracotomy and upper hemi-sternotomy approach with recent smaller LVAD is feasible and can be done with short cardio-pulmonary bypass time for patients who do not need other valvular procedures. This approach may potentially provide better clinical outcome, such as shorter ICU stay, RV protection and safer re-entry in future re-operation. Further investigation is required for better understanding of the true benefit of this innovative approach.
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