Initial experience with routine less invasive implantation of HeartMate II left ventricular assist device without median sternotomy

Objectives: Standard implantation of HeartMate II (HMII) left ventricular assist device requires an extended median sternotomy; this incision, while generally well tolerated, may add morbidity in critically ill debilitated patients. We recently adopted a sternum sparing technique for routine HMII implants using a left subcostal incision to create a pocket and access the left ventricular apex, and a right minithoracotomy to access the ascending aorta.

Methods: Retrospective analysis of 40 consecutive patients (M:F 32 : 8; age range 48-77 years; Interagency Registry for Mechanically Assisted Circulatory Support 1 = 8; 2 = 10; 3 or 4 = 22) who underwent implantation of HMII using a non-sternotomy approach in a single institution.

Results: HMII insertion was completed with the less invasive technique in all cases with no conversions to full sternotomy. There were no reoperations for bleeding and 70% of patients did not have any intraoperative blood product transfusion. No patient required right ventricular assist device support. Majority of patients (80%) were extubated by postoperative day 1. There were no wound, mediastinal or pocket infections. One patient suffered a new perioperative stroke. Median postoperative hospital stay was 19 days. Operative mortality was 7.5% and 12-month actuarial survival was 86 ± 6%.

Conclusions: Primary HMII implantation without median sternotomy is feasible and can be safely, effectively and routinely applied, using our less invasive approach. Further investigation is necessary to determine whether the non-invasive technique contributed to the low incidence of bleeding, blood transfusion, respiratory morbidity and right ventricular failure seen in this study.