Khalil Jawad1, Firat Sipahi2, Alex Koziarz3, Simone Huhn4, Nikos Kalampokas2, Alexander Albert2, Michael A Borger4, Artur Lichtenberg2, Diyar Saeed5. 1. Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany; Cardiac Surgery, Peter Munk Cardiac Center, University of Toronto, Toronto, Ontario, Canada. 2. Cardiac Surgery, Düsseldorf University Hospital, Dusseldorf, Germany. 3. Cardiac Surgery, Peter Munk Cardiac Center, University of Toronto, Toronto, Ontario, Canada. 4. Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany. 5. Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany; Cardiac Surgery, Düsseldorf University Hospital, Dusseldorf, Germany. Electronic address: diyar.saeed@helios-gesundheit.de.
Abstract
BACKGROUND: Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach. METHODS: Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation. RESULTS: The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77). CONCLUSIONS: The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.
BACKGROUND: Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach. METHODS: Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation. RESULTS: The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77). CONCLUSIONS: The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.
Authors: Federico Pappalardo; Evgenij Potapov; Antonio Loforte; Michiel Morshuis; David Schibilsky; Daniel Zimpfer; Julia Riebandt; Christian Etz; Matteo Attisani; Mauro Rinaldi; Assad Haneya; Faiz Ramjankhan; Dirk Donker; Ulrich P Jorde; Daniel Lewin; Radi Wieloch; Rafael Ayala; Jochen Cremer; Letizia Bertoldi; Michael Borger; Artur Lichtenberg; Jan Gummert; Diyar Saeed Journal: Interact Cardiovasc Thorac Surg Date: 2022-03-31