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International Society For Minimally Invasive Cardiothoracic Surgery

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Development Of A Total Endoscopic Approach To Left Ventricular Assist Device Outflow Graft Anastomosis
Kyle C. Purrman1, Eric Ndikumana2, Jude S. Sauer1, Peter A. Knight2, Igor Gosev2.
1LSI SOLUTIONS, Victor, NY, USA, 2University of Rochester Medical Center, Rochester, NY, USA.

BACKGROUND: Less invasive surgical techniques for left ventricular assist device (LVAD) implantation offer encouraging options for improved clinical outcomes, especially for potential bridge to transplant patients. Rapid and reliable techniques enabling total endoscopic LVAD outflow conduit to ascending aorta anastomoses may further reduce surgical access related trauma and enhance recovery. An early evaluation of the feasibility and ergonomics of a recently developed new anastomotic approach is reported.
METHODS: This study utilized a custom cardiac surgery simulation model incorporating ex vivo porcine hearts and including a 5 mm camera port in the third intercostal space (ICS) anterior axillary line; two 11 mm working ports in the second and fourth ICSs midclavicular line; and a 5 mm side biting clamp port in the first ICS midclavicular line. Ten 14 mm polyester conduit to isolated mid-anterior ascending aorta anastomoses were manually sewn with a shafted needle driver using standard curved needles with 3-0 polypropylene suture in a simple interrupted pattern. Each anastomotic suture was secured with titanium fastener. Real-time data were recorded.
RESULTS: The mean time to complete this study’s 10 endoscopic anastomoses was 17 minutes, 22 seconds (14:03-21:34) with an average number of sutures placed per anastomosis of 12.8 (11-15). A 10 point Likert scale enabled measurement of surgeon-reported satisfaction associated with setting up the procedure (e.g., port placement, visualization, etc.) as 6.3 (4-8) and conducting the procedure (e.g., tissue/graft manipulation, anastomotic suturing) as 8.2 (8-9). Anastomoses were pressure tested with infused saline for potential leakage and rated on a 5 point scale (none=0 to 5=massive); the mean rating was 0.7 (0-2), which was considered trivial. Each anastomosis was imaged under magnification for possible compromise, such as gaps or strictures. Nine of ten anastomoses exhibited no concerns; an area of stenosis was noted in one anastomosis.
CONCLUSION: While recent developments of less invasive techniques for LVAD implantation are encouraging, opportunities for critical improvement remain. Early evaluation of the feasibility and ergonomics of this new suturing approach have demonstrated favorable results regarding totally endoscopic LVAD outflow graft to ascending aorta anastomoses. Additional preclinical and clinical evaluations are planned.

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