No Visible Scars Implantation of a Continuous Flow Ventricular Assist Device
Ventricular assist device surgery using a lateral access has been shown to be a safe and a partially beneficial alternative to the standard approach by sternotomy (1). Hereby, left anterolateral minithoracotomy is obligatory for accessing the apex, but for facilitating the outflow-graft anastomosis mainly two options are described: (I) partial upper sternotomy and (II) right anterior minithoracotomy using the second intercostal space (2). Both are well established techniques, but still have the need for either cutting the sternum or the ribs.
Herein, we describe a new technique leaving the osseous thorax completely untouched: The right lateral or transaxillary access for outflow graft anastomosis combined with a left anterolateral minithoracotomy.
The used right lateral or transaxillary access has been described for isolated aortic valve or combined aortic and mitral valve surgery (3, 4, 5). The used access is based on a 5cm skin incision in the right anterior axillary line. The thorax is opened in the 3rd intercostal space without dissection of any ribs. Only using a soft-tissue retractor and gentle rib-spreading, the aorta easily can be reached. Extracorporal circulation is established using femoral cannulation.
The technique is described in a detailed step-to-step video. In this female patient, surgical access sites disappear (I) in the right axilla and (II) below the breast, resulting in a No-Visible-Scars-HVAD (Medtronic, Minneapolis, MN, USA) Implantation.
(1) McGee E Jr, Danter M, Strueber M, Mahr C, Mokadam NA, Wieselthaler G, Klein L, Lee S, Boeve T, Maltais S, Pretorius GV, Adler E, Vassiliades T, Cheung A. Evaluation of a lateral thoracotomy implant approach for a centrifugal-flow left ventricular assist device: The LATERAL clinical trial. J Heart Lung Transplant. 2019 Apr;38(4):344-351. doi: 10.1016/j.healun.2019.02.002. PMID: 30945636.
(2) Al-Naamani A, Fahr F, Khan A, Bireta C, Nozdrzykowski M, Feder S, Deshmukh N, Jubeh M, Eifert S, Jawad K, Schulz U, Borger MA, Saeed D. Minimally invasive ventricular assist device implantation. J Thorac Dis. 2021 Mar;13(3):2010-2017. doi: 10.21037/jtd-20-1492. PMID: 33841987; PMCID: PMC8024790.
(3) Wilbring M, Arzt S, Alexiou K, Matschke K, Kappert U. Surgery without visible scars-double valve surgery using the right lateral access. Ann Cardiothorac Surg. 2020 Sep;9(5):424-426. doi: 10.21037/acs.2020.03.16. PMID: 33102183; PMCID: PMC7548216.
(4) Wilbring M, Matschke KE, Alexiou K, Di Eusanio M, Kappert U. Surgery without Scars: Right Lateral Access for Minimally Invasive Aortic Valve Replacement. Thorac Cardiovasc Surg. 2020 Oct 19. doi: 10.1055/s-0040-1713137. Epub ahead of print. PMID: 33075824.