Madeline Fryer, MD, MMSc and Katherine Wood, MD
University of Rochester, Rochester, NY, USA
Essential Operative Steps
- Invasive monitoring, general anesthesia
- Left lateral thoracotomy
- Open pericardium to expose LV apex
- Right anterior thoracotomy at [2nd] intercostal space, ligation of RIMA, and disarticulation of [3nd] rib
- Open pericardium to expose ascending aorta
- Systemic heparinization, central arterial cannulation, peripheral venous cannulation
- Initiation of cardiopulmonary bypass
- Secure sewing ring to LV apex
- Tunnel driveline
- Pass/position outflow graft
- Partial aortic clamping and outflow graft anastomosis
- Core LV, pump placement
- Pump on with aggressive deairing
- Ramp up pump speeds and wean from CPB under TEE guidance
- Give protamine, ensure hemostasis, decannulate
- Close thoracotomy sites and secure driveline
Potential Complications and Pitfalls
- Poor exposure due to thoracotomy in incorrect rib space
- Poor exposure due to small intercostal spaces or small thoracotomy incision
- Phrenic nerve injury while exposing LV
- Cannulation issues (aortic dissection/bleeding, short ascending aorta, femoral artery/vein injuries)
- Injury to abdominal organs while tunneling driveline
- Inadequate tachycardia pacing during left ventricle coring (if performing off-pump)
- Twisted, kinked, or mis-sized outflow graft
- Air embolus from inadequate deairing or LV coring prior to Impella removal
We recommend non-contrast CT chest in all patients for surgical planning. If there is a history of prior CABG, we recommend
obtaining CTA of the chest to identify the grafts and confirm patency (if there is no recent angiogram). Transthoracic
echocardiography is helpful for identifying the left ventricular apex and correct intercostal space for the left thoracotomy. If
there is inadequate exposure, a rib adjacent to the thoracotomy may be disarticulated or shingled. Take care to identify the
phrenic nerve bilaterally before opening the pericardium. If exposure is difficult or poor in the right anterior thoracotomy,
femoral arterial cannulation can be considered to allow more space for partial aortic clamp. Transesophageal echocardiography
is useful for optimizing the coring site and inflow positioning of the LVAD. Marking the outflow graft and having one surgeon
tunnel it from the left to right chest decreases the risk of twisting or kinking. Flooding the field with carbon dioxide can
minimize intracardiac air at time of coring.
Template Dictation
Preoperative Diagnosis: [BLANK]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: On-Pump Sternal Sparing Insertion of VAD via Bilateral Thoracotomies
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indications for Procedure: The patient is a [AGE]-year-old [SEX] with a [DURATION] history of [CHIEF COMPLAINT
– e.g. idiopathic dilated cardiomyopathy, ischemic cardiomyopathy]. Preoperative workup showed [FINDINGS]. The patient
was NYHA/ACC/AHA Class [FUNCTIONAL CLASS PRIOR TO PROCEDURE] and INTERMACS Profile
[NUMBER]. After being presented in our multidisciplinary heart failure conference, they presented today for [DEVICE
TYPE] LVAD implantation.
Description of the Procedure: The patient was taken to the operating room and placed in supine position. They were placed
under general anesthesia, prepped, and draped in a sterile fashion. Appropriate invasive monitoring lines were already in place
including an arterial line and PA catheter. The TEE probe was placed by the anesthesiologist. A surgical timeout was performed
and [ANTIBIOTICS] were given within 60 minutes of the incision.
A 10cm incision was made under the left inframammary crease and the chest wall was exposed. Transthoracic echo was used
to confirm the correct interspace. The [NUMBER] intercostal interspace was entered and the [NUMBER] rib was
disarticulated at the sternocostal joint. The pericardium was opened to expose the LV apex while taking care to preserve the
phrenic nerve.
A 5cm incision was made in the right 2nd rib space next to the sternum. The right pectoralis major muscle was split, and the
right internal mammary vessels were ligated. The 2nd rib was disarticulated from the sternum using electrocautery. The
pericardium was then opened from the pericardial reflection to the level of the SVC and RA junction providing exposure of
the aorta.
Full dose IV heparin was given to the patient to maintain an ACT of greater than [NUMBER]seconds. An aortic cannula was
then placed in the ascending aorta using Seldinger technique. The right common femoral vein was accessed percutaneously.
An Amplatz Extra stiff 0.035inch wire was passed to the level of the SVC under TEE guidance. The vein was serially dilated,
and a femoral venous cannula was placed to the level of the SVC.
After identification of the true apex using TEE, the sewing ring was secured to the left ventricle with partial thickness,
interrupted, pledgeted 2-0 ethibond sutures. The driveline was tunneled to the [RIGHT/LEFT] upper quadrant of the abdomen
in the pre-marked location and connected to the controller. The outflow graft was measured and cut to the appropriate length
with a 60-degree bevel. The outflow graft was carefully passed lateral to the RA and along the acute margin of the RV.
A partial crossclamp was placed on the greater curve of the ascending aorta and aortotomy performed. The outflow graft was
then anastomosed to the aorta with 4-0 prolene and reinforced with Bioglue. The graft was clamped, the partial aortic
crossclamp was removed, and the graft deaired. The outflow graft was connected to the pump after inspection to ensure no
twisting. Cardiopulmonary bypass was initiated.
TEE confirmed there was no visible LV thrombus. The patient was placed in steep Trendelenburg position. A circular
ventriculotomy was made in the left ventricular apex. The LV core was removed, and the LV was inspected for thrombus.
Obstructing trabeculations were removed. The pump was connected to the sewing ring and locked in place. The bend relief
was secured to the pump.
The pump was initiated at a speed of 4000RPM and aggressively deaired with a venting needle in the outflow graft. The flow
on the LVAD was gradually increased and the patient was weaned off bypass. This was successfully achieved on the
[NUMBER] attempt without complication. Right ventricular function was [NORMAL/DEPRESSED]. Post-implant
evaluation by TEE demonstrated [SEVERITY] AI, [SEVERITY] MR, [SEVERITY] TR, and [ABSENT/PRESENT] PFO.
The interventricular septum was positioned midline with the LVAD at [SPEED]rpm.
Protamine was started. We examined the heart for bleeding. The aortic and venous cannulas were removed. [NUMBER] chest
tubes were placed into the mediastinum and pleural spaces. A 15×20 cm Gore-Tex 0.1 mm thick sheet was then attached to the
pericardium with 4-0 prolene suture and later folded over the LVAD pump to protect it from adhesions. A small portion of this
sheet was also placed over the ascending aorta to close the pericardiotomy. The sternal thickness and rib thickness were
measured using the caliper. The disarticulated right 3rd rib was reduced with bone reduction clamps. A 4-hole straight
Sternalock Blu plate was contoured and secured to the manubrium and 3rd rib with [SIZE]mm, self-drilling, self-tapping,
locking screws. The wounds were irrigated copiously and closed with suture in multiple layers. The driveline exit site was
closed with suture and then anchored with #1 prolene suture. The driveline exit site was covered with dry gauze and sterile
dressing.
Sponge, instrument, and needle counts were correct at the conclusion of the case. The patient was taken to the ICU in critical
condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
- Which of the following is the most serious contraindication to LVAD implantation?
A. Moderate to severe aortic regurgitation
B. Moderate to severe mitral regurgitation
C. Patent foramen ovale/Atrial septal defect
D. Severe coronary artery disease
E. Ventricular arrhythmias
Answer: A. Moderate to severe aortic regurgitation. Aortic insufficiency increases the risk for recirculation of blood flow
through the LVAD without systemic circulation.
- Which of the following structures is intentionally divided during minimally invasive LVAD implantation?
A. Left internal mammary artery (LIMA)
B. Right internal mammary artery (RIMA)
C. Left phrenic nerve
D. Right phrenic nerve
E. Azygos vein
Answer: B. Right internal mammary artery. The RIMA is ligated during the right mini-thoracotomy to expose the ascending
aorta. - Which of the following is not a critical risk of minimally invasive LVAD implantation?
A. Embolic stroke
B. Right ventricular failure
C. LAD injury
D. Uncontrolled LV hemorrhage
E. Enterotomy or liver injury
Answer: C. LAD injury. Although the LAD is at risk of ligation during placement of the sewing ring and left ventriculotomy,
LAD injury is of minimal consequence in patients already in severe heart failure with durable mechanical circulatory support.
Sources
Wood KL, Ayers BC, Sagebin F, Vidula H, Thomas S, Alexis JD, Barrus B, Knight P, Prasad S, Gosev I. Complete SternalSparing HeartMate 3 Implantation: A Case Series of 10 Consecutive Patients. Ann Thorac Surg. 2019 Apr;107(4):1160-1165.
doi: 10.1016/j.athoracsur.2018.10.005. Epub 2018 Nov 13. PMID: 30444989.
