Right Ventricular Function Following Sternotomy Versus a Less-Invasive Approach for Left Ventricular Assist Device Implant: Retrospective Cohort Study

Terri Sun; Paul Yen; Defen Peng; Laura Besola; Wynne Chiu; Alana Flexman; Anson Cheung

doi:10.1053/j.jvca.2024.04.044

Right Ventricular Function Following Sternotomy Versus a Less-Invasive Approach for Left Ventricular Assist Device Implant: Retrospective Cohort Study

J Cardiothorac Vasc Anesth. 2024 Apr 27:S1053-0770(24)00301-X. doi: 10.1053/j.jvca.2024.04.044. Online ahead of print.

Authors

Terri Sun¹, Paul Yen², Defen Peng³, Laura Besola⁴, Wynne Chiu⁵, Alana Flexman⁶, Anson Cheung⁵

Affiliations

¹ Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesiology, Providence Health Care, Vancouver, BC, Canada. Electronic address: terri.sun@gmail.com.
² Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
³ Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada.
⁴ Department of Anesthesiology, Providence Health Care, Vancouver, BC, Canada.
⁵ Division of Cardiothoracic Surgery, University of British Columbia, Vancouver, BC, Canada.
⁶ Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesiology, Providence Health Care, Vancouver, BC, Canada.

PMID: 39482175
DOI: 10.1053/j.jvca.2024.04.044

Abstract

Objectives: Durable left ventricular assist device (LVAD) implantation is traditionally performed via median sternotomy (MS). Less-invasive implantation may lower the incidence of postimplant right ventricular failure (RVF). Our primary objective was to determine whether less-invasive implantation reduces the odds of severe RVF compared to MS.

Design: Retrospective cohort study.

Setting: St. Paul's Hospital, Vancouver, BC, Canada.

Participants: One hundred ninety-eight adult patients between January 2008 and August 2021.

Interventions: Isolated LVAD implantation either via median sternotomy or via a less-invasive surgical approach.

Measurements and main results: Multivariable logistic regression was used to adjust for confounders. A sensitivity analysis using inverse probability of treatment weighting analysis based on propensity scores was conducted. One hundred seventy-two patients were analyzed; 54% (94/172) underwent LVAD implantation via MS, and 45% (78/172) via less-invasive approaches. Age, sex, and comorbidities were comparable, but the MS group tended to be more critically ill prior to surgery. After adjusting for confounders, less-invasive approaches did not show significant protection against severe postimplant RVF compared to MS (adjusted odds ratio 0.53; 95% confidence interval 0.20-1.44; p = 0.21). However, patients undergoing less-invasive techniques had reduced adjusted odds of 30-day mortality (odds ratio 0.29; 95% confidence interval 0.09-0.99); p = 0.049). There was no observed benefit of less-invasive approaches over MS for major bleeding, prevention of blood product transfusion, and listing for transplantation.

Conclusions: There was no reduction in the odds of severe RVF following LVAD implantation using less-invasive approaches versus MS. However, we found improved odds of 30-day survival in the less-invasive group. The underlying mechanism requires further investigation.

Keywords: 30-day mortality; implantation; left ventricular assist device; less-invasive; median sternotomy; right ventricular failure; surgical approach.