Stroke and Pump Thrombosis following LVAD Implantation: Impact of the Implantation Approach

Background: Several studies have shown the potential advantage of less invasive (LIS) ventricular assist device implantation on early hemodynamic and right ventricular function. However, the impact of LIS implantation technique on the long-term VAD-related morbidities is unknown. The aim of this study is to investigate the impact of VAD implantation technique on postoperative morbidities, with special focus on stroke and pump thrombosis.

Method: A retrospective data analysis was performed between 01/2015 and 08/2021 to identify patients who underwent LVAD implantation using either standard sternotomy (ST) approach or LIS approach. The LIS implantation was performed using a partial J-shaped sternotomy in the 3rd ICR with a left anterior mini-thoracotomy. All patients were followed up until August 2021. Postoperative outcome was compared between ST and LIS groups.

Results: A total of 355 patients (mean age: 58.9 ± 11.3 years) received LVAD during this period. Sternotomy was used in 255 (F = 36; 14.1%) patients and LIS in 100 patients (F = 9; 9.0%). The mean age of LIS group was 60.0 ± 10.1 years versus 58.4 ± 11.7 in ST group (p = 0.245). The median follow-up of LIS group was 241 vs. 301 in ST group (p = 0.994) days.

In LIS group, 42 patients (43.3%) had ischemic, and 53 (54.6%) patients had dilated cardiomyopathy. This was comparable to 123 (49.2%) ischemic and 117 (46.8%) dilated cardiomyopathy in ST group (p = 0.342). The following systems were implanted in LIS group: HW in 40 (40.0%), HM III in 59 patients (59.0%), and HM II in 1 patient (1.0%). Meanwhile, in ST group: HW in 61 (23.9%), HM III in 180 patients (70.6%), and 14 HM II (5.5%).

Postoperative bleeding required reoperation occurred significantly less often in the LIS group (n = 46 LIS vs. n = 7 ST, p = 0.008). The rate of perioperative ischemic stroke showed no significant difference (n = 15 ST vs. n = 4 LIS, p = 0.605), same with perioperative intracranial bleeding (n = 10 ST vs. n = 6 LIS, p = 0.402). The early (up to 30 days after LVAD implantation) pump thrombosis rate (n = 1 LIS vs. n = 2 ST, p = 1.0) did not differ between the groups.

Thirty-day mortality rate was 7.0% in LIS and 8.7% in ST group (p = 0.673). Observed survival rate during the follow-up was 38% in LIS and 34% in ST group (p = 0.147 in log-rank test).

Conclusion: LIS approach for VAD implantation is a safe procedure with potential advantage in the early postoperative period. However, postoperative stroke, pump thrombosis, and outcome remain comparable to sternotomy approach.

Publication History

Article published online:
03 February 2022