Minimally invasive approaches for implantation of left ventricular assist devices

Transversus thoracic plane block and rectus sheath block for left ventricular assist device implantation via full median sternotomy: A case report

BACKGROUND

Traditionally, pain management after left ventricular assist device (LVAD) implantation via median sternotomy have been based on intravenous opioids but, in the era of enhanced recovery after surgery, a multimodal opioid-sparing analgesia could represent a valid alternative reducing opioids related side effects.

CASE REPORT

We described the successfully use of an opioid-sparing regimen for pain management after LVAD implantation via median sternotomy based on two ultrasound-guided fascial plane wall blocks. Bilateral ultrasound-guided transversus thoracic plane block was performed to manage sternotomy pain; additionally, unilateral left ultrasound-guided rectus sheath block was performed to provide somatic pain relief for left abdominal wall structures superficial to the peritoneum within which the LVAD driveline was inserted. The patient was extubated on Day 1 and good quality analgesia (numerical rating scale <3) was obtained, without using nonsteroidal antiinflammatory drugs or opioids. The patient was discharged from Intensive Care Unit on Day 3 and during hospitalization (lasted 24 days) there was no need for rescue analgesia administration.

LVAD implantation to Left Subclavian Artery with Distal Banding: A Novel Technique for Hostile Chest

Patients with hostile chests are often precluded from the use of LVAD therapies for advanced heart failure. We describe a technique for LVAD implantation using a left thoracotomy approach with outflow graft anastomosis to the left subclavian artery and placement of a distal band to the left subclavian artery. Distal banding of the left subclavian artery prevents overcirculation to the left upper extremity. This technique provides an alternative approach for LVAD implantation in patients who otherwise would be deemed inoperable due to hostile chest.

Exercise capacity following ventricular assist device implantation via thoracotomy with outflow cannula anastomosis to the descending aorta

Left ventricular assist device (LVAD) implantation via left lateral thoracotomy with outflow cannula anastomosis to the descending aorta is an alternative technique that avoids anterior mediastinal planes and requires a single incision. This study compares changes in exercise capacity following LVAD implantation with outflow cannula anastomosis to the descending aorta versus ascending aorta. Adult patients who received a continuous flow centrifugal LVAD implantation and completed both pre- and postimplantation cardiopulmonary exercise tests (CPETs) and or 6-minute walk tests (6MWT) were included. Change in CPET parameters (maximum oxygen intake: vO₂ max, oxygen uptake efficiency ratio: OUES, ventilatory efficiency ratio: vE/vCO₂ Slope) and 6MWT distance were compared between ascending and descending aorta anastomosis groups. Ascending and descending aorta anastomosis cohorts included 59 and 14 patients, respectively. Pre- and postimplantation CPETs were performed 63 ± 12 days before and 216 ± 17 days following implantation. The improvement in CPET parameters (vO₂ max, OUES, vE/vCO₂ Slope) or 6MWT distance was not significantly different between the ascending and descending aorta anastomosis groups. This study found no significant difference in the improvement of CPET parameters or 6MWT distance between LVAD implantation via thoracotomy with outflow cannula anastomosis to descending aorta and standard implantation via sternotomy with outflow cannula anastomosis to ascending aorta.