Minimally invasive surgery improves outcome of left ventricular assist device surgery in cardiogenic shock.

BACKGROUND: Left ventricular assist device (LVAD) (HVAD, Medtronic, Minneapolis, MN, USA) implantation is already a widely accepted treatment option for end-stage heart failure (HF) but also still considered as a rescue therapy for patients suffering from cardiogenic shock. Standard LVAD implantation techniques are often associated with high mortality rates and can result in severe complications, like bleeding or right heart failure (RHF). The aim of our study was to assess the outcome of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients (so called "crash and burn" patients) undergoing a LVAD implantation by standard or less invasive surgery. METHODS: We performed a retrospective evaluation of the 1-year outcome of 32 consecutive HF patients in cardiogenic shock, who underwent LVAD implantation in our institution. A total of 32 INTERMACS 1 patients were emergently operated. Fourteen patients (group A) were operated by using the "Hannover-VAD-technique", which is widely known to be less invasive (upper hemisternotomy and a left-sided anterolateral thoracotomy). In contrast, 18 patients (group B) were implanted with LVAD by using the standard technique (full sternotomy). The primary endpoint was survival after 1 year without device-related re-operations. Secondary endpoints included combined analyses of rates of RHF, respiratory failure and bleeding during the trial period. RESULTS: Baseline characteristics were similar in both groups. Survival after 1 year was higher in group A (69.7% vs. 50.0%). Technique-related adverse events (AEs) were also lower in the minimally invasive group, including a lower RHF (35.7% vs. 61.1%) and of further postoperative bleeding requiring surgery (14.3% vs. 33.3%). CONCLUSIONS: LVAD surgery in INTERMACS 1 patients is associated with remarkably good outcome considering the already very high mortality of those patients, and compared to previously reported surgical outcomes. Our study indicates that minimally invasive LVAD implantation in cardiogenic shock decreases mortality and the incidence of postoperative AEs.

Asistencia ventricular izquierda como terapia de destino: ¿la cirugía mínimamente invasiva es una alternativa segura? / Left ventricular assist device therapy for destination therapy: is less invasive surgery a safe alternative?

Introducción y objetivos: El número de pacientes ancianos con insuficiencia cardiaca terminal ha crecido espectacularmente. Considerando que el número de trasplantes cardiacos se ha estancado, se requiere una alternativa terapéutica. Desde hace poco se están aplicando como terapia de destino (TD) dispositivos de asistencia ventricular izquierda (DAVI). Asumiendo que los pacientes de más edad tienen mayor riesgo quirúrgico, es presumible que la cirugía menos invasiva (CMI) para el DAVI contribuya a mejorar los resultados operatorios en pacientes en TD. Métodos: Se realizó un estudio prospectivo con un seguimiento de 2 años de 46 pacientes en TD (edad mayor de 60 años) consecutivos a los que se trató con DAVI (HVAD, HeartWare) en nuestra institución entre 2011 y 2013. Se formaron 2 grupos según el método quirúrgico de implante: CMI (n = 20) o cirugía convencional (n = 26). Resultados: A pesar de que no se hallaron diferencias estadísticas significativas respecto a la supervivencia a 2 años, sí se observó una tendencia a mayor supervivencia en el grupo CMI (el 85,0 frente al 69,2%; p = 0,302). Asimismo, los pacientes del grupo de CMI presentaron menor incidencia de hemorragias tras la cirugía (0 frente al 26,9%; p < 0,05), junto con menores tasas de uso prolongado de inotrópicos tras la cirugía (el 15,0 frente al 46,2%; p < 0,05). Conclusiones: Los datos indican que los pacientes sometidos a CMI para implante de DAVI como TD muestran tras la cirugía menor incidencia de hemorragias, menor necesidad de apoyo con inotrópicos y una tendencia a menor mortalidad que los pacientes operados de manera convencional (AU)

Introduction and objectives: The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients. Methods: We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26). Results: There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P < .05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P < .05). Conclusions: Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique (AU)

Left Ventricular Assist Device Therapy for Destination Therapy: Is Less Invasive Surgery a Safe Alternative?

INTRODUCTION AND OBJECTIVES: The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients. METHODS: We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26). RESULTS: There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P < .05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P < .05). CONCLUSIONS: Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique.