Commentary: Uplifting or down the rabbit hole?
2021; Elsevier BV; Volume: 7; Linguagem: Inglês
10.1016/j.xjtc.2021.03.011
ISSN2666-2507
Autores Tópico(s)Cardiac Structural Anomalies and Repair
ResumoCentral MessageA retractor that can lift the manubrium has been tested in cadavers for mini VAD insertion. The outflow graft can be anastomosed to the aorta without hemi-sternotomy.See Article page 192. A retractor that can lift the manubrium has been tested in cadavers for mini VAD insertion. The outflow graft can be anastomosed to the aorta without hemi-sternotomy. See Article page 192. I was raised in the era of "big docs make big incisions." No one questioned the 10-inch subcostal approach to the hot gall bladder, and the 6-inch McBurney was a badge of appendiceal courage. The access for surgery on and in the heart evolved from a bilateral sternum-splitting intercostal incision, which I still use for transplantation of en bloc heart and lungs and of double lungs. Today, full sternotomy remains the standard; however, its reliable exposure of the heart, excellent healing, and only modest pain has been under assault since 1995, when John Stevens and Wes Sterman founded Heartport Inc, and Tom Fogarty pushed surgeons with the promise of "keyhole" surgery. The hype inflamed by Internet videos of "chest cracking" made us feel awful about the continuing use of buzzing reciprocating sternal saws. Robotic assist to the mitral valve followed, with Randy Chitwood demonstrating remarkable visualization. Damiano demonstrated its added precision to off-pump mammary to left anterior artery anastomoses, and a few dedicated surgeons persist with robotic multivessel coronary artery bypass grafting surgery. Most recently, to keep pace with transcatheter aortic valve replacement, many surgeons have mastered the upper hemi-sternotomy or right anterior thoracotomy for surgical aortic valve replacement. I have tried all of these, but generally have returned to the midline sternotomy, but with a cosmetic, small skin incision. A minimally invasive thoracotomy and upper hemi-sternotomy approach to a ventricular assist device was popularized by Schmitto and colleagues.1Schmitto J.D. Krabatsch T. Damme L. Netuka I. Less invasive HeartMate 3 left ventricular assist device implantation.J Thorac Dis. 2018; 10: S1692-S1695Crossref PubMed Scopus (22) Google Scholar Zach Kon, then of our group, observed the Hannover surgeons and learned that the incidence of right ventricular failure had become negligible. We also noted a reduction in postoperative disabling right heart failure.2Sorensen E.N. Griffith B.P. Feller E.D. Kaczorowski D.J. Outcomes with temporary mechanical circulatory support before minimally invasive centrifugal left ventricular assist device.J Card Surg. 2020; 35: 1539-1547Crossref PubMed Scopus (1) Google Scholar, 3Pasrija C. Sawan M.A. Sorensen E.N. Voorhees H.J. Shah A. Wang L. et al.Less invasive approach to left ventricular assist device implantation may improve survival in high-risk patients.Innovations (Phila). 2020; 15: 243-250Crossref PubMed Scopus (2) Google Scholar, 4Voorhees H.J. Sorensen E.N. Pasrija C. Kaczorowski D. Griffith B.P. Kon Z.N. Outcomes of obese patients undergoing less invasive LVAD implantation.J Card Surg. 2019; 34: 1465-1469Crossref PubMed Scopus (5) Google Scholar, 5Shah A. Kaczorowski D.J. Minimally invasive durable mechanical circulatory support: don't hit them while they're down.J Thorac Cardiovasc Surg. 2019; 157: e269-e270Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 6Pasrija C. Sawan M.A. Sorensen E. Voorhees H. Shah A. Strauss E. et al.Less invasive left ventricular assist device implantation may reduce right ventricular failure.Interact Cardiovasc Thorac Surg. 2019; 29: 592-598Crossref PubMed Scopus (23) Google Scholar The mini approach seems to make transplant simpler and with less hemorrhage.7Rabin J. Ziegler L.A. Cipriano S. Madathil R.J. Feller E.D. Sorensen E.N. et al.Minimally invasive left ventricular assist device insertion facilitates subsequent heart transplant.Innovations (Phila). January 7, 2021; ([Epub ahead of print])Crossref PubMed Scopus (2) Google Scholar It has been known that maintenance of pericardial support and restraint reduces loss of right ventricular transverse diameter, long-axis velocity, and tricuspid annular phase systolic excursion seen with opening of the pericardium in coronary artery bypass grafting patients.8Unsworth B. Casula R.P. Kyriacou A.A. Yadav H. Chukwuemeka A. Cherian A. et al.The right ventricular annular velocity caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision.Am Heart J. 2010; 159: 314-322Crossref PubMed Scopus (107) Google Scholar Similar studies need to be repeated in standard approaches to VAD patients with ischemic cardiomyopathy and nonischemic cardiomyopathy plus variable degrees of right ventricular dysfunction. The LATERAL trial did not show inferiority, but it was a noncomparison trial.9McGee Jr., E. Danter M. Strueber M. Mahr C. Mokadam N.A. Wieselthaler G. et al.Evaluation of a lateral thoracotomy implant approach for a centrifugal-flow left ventricular assist device: the LATERAL clinical trial.J Heart Lung Transplant. 2019; 38: 344-351Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar It is likely that the merits of the mini for right ventricular function will require additional experience. The article describes a retractor and imaging system to lift an undivided upper sternum to expose the ascending aorta.10Sutherland F.W.H. Grandinariu G. Curry P. Transcervical approach for left ventricular assist device outflow graft: a proof-of-concept implantation study.J Thorac Cardiovasc Surg Tech. 2021; 7: 192-194Scopus (2) Google Scholar This access is evaluated in Thiel soft-fixed cadavers as a feasible technique for connecting the outflow graft of a VAD placed by a small fifth intercostal space thoracotomy. The authors report impressive exposure of the ascending aorta and use of a standard Derra–Cooley partial occlusion clamp to complete a running anastomosis. It is likely this will preserve the possible benefits of the hemi and reduce the implant to the small thoracotomy. For most of us traumatized by the minimally invasive surgical tsunamis of the past, we can gain solace from the inimitable Bruce Lytle, who summed up a wait-and-see-attitude with a line from Bruce Springsteen's song "Thunder Road":"The door's open, but the ride ain't free."11Springsteen B. Thunder Road. Columbia-Sony, New York1975https://genius.com/Bruce-springsteen-thunder-road-lyricsDate accessed: March 12, 2021Google Scholar Transcervical approach for left ventricular assist device outflow graft: A proof-of-concept implantation studyJTCVS TechniquesVol. 7PreviewMinimally invasive techniques to implant centrifugal left ventricular assist devices (LVADs) have been described as alternatives to the classic full sternotomy approach. Implantation of the pump is done through a left anterior thoracotomy. The outflow graft is anastomosed to the ascending aorta via upper hemisternotomy or right anterior thoracotomy.1,2 Full-Text PDF Open Access
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