Improved Approach With Subcostal Exchange Of The Heartmate Ii Left Ventricular Assist Device: Difference In On And Off Pump?

Background. The HeartMate II (St. Jude Medical, Inc, St. Paul, MN [previously Thoratec]) left ventricular assist device (LVAD) exchange has traditionally involved a redo sternotomy. Alternate minimally invasive subcostal approaches have the advantage of avoiding sternal reentry, excessive bleeding, and prolonged recovery.& para;& para;Methods. This retrospective review included patients who underwent an exchange from May 2009 to March 2016. The patients were divided into three cohorts: (1) redo sternotomy, (2) subcostal approach involving cardiopulmonary bypass (CPB) (ON-CPB SC), and (3) subcostal approach off the CPB pump (OFF-CPB SC). Data pertaining to patients' baseline characteristics and out comes were collected and analyzed.& para;& para;Results. From May 1, 2009 to July 31, 2016, 33 Heart-Mate II LVAD exchanges were performed. There were 11 redo sternotomies and 22 subcostal exchanges, 12 of which were in the OFF-CPB SC group. There was no significant difference among the groups in terms of age (p = 0.75), sex (p = 0.95), and indication for exchange (p = 0.94). There was a higher red blood cell transfusion requirement within the sternotomy cohort (p < 0.001). The median time to extubation and the intensive care unit length of stay were significantly shorter in the OFF-CPB SC group (1 and 2.5 days, respectively) than in the sternotomy (2.5 and 21 day, respectively) and ON-CPB SC groups (1.5 and 5 days, respectively). The 30-day and 90-day survival rates were equivalent among the cohorts.& para;& para;Conclusions. Exchange of the HeartMate II LVAD can be accomplished with significantly improved recovery time and transfusion requirement through a less invasive subcostal approach when compared with sternotomy. The subcostal approach can be performed safely both on and off cardiopulmonary bypass. (C) 2017 by The Society of Thoracic Surgeons