title: Initial experience with routine less invasive implantation of HeartMate II left ventricular assist device without median sternotomy.
abstract: OBJECTIVE
  Standard implantation of HeartMate II (HMII) left ventricular assist device requires an extended median sternotomy; this incision, while generally well tolerated, may add morbidity in critically ill debilitated patients. We recently adopted a sternum sparing technique for routine HMII implants using a left subcostal incision to create a pocket and access the left ventricular apex, and a right minithoracotomy to access the ascending aorta.
  
  
  METHODS
  Retrospective analysis of 40 consecutive patients (M:F 32 : 8; age range 48-77 years; Interagency Registry for Mechanically Assisted Circulatory Support 1 = 8; 2 = 10; 3 or 4 = 22) who underwent implantation of HMII using a non-sternotomy approach in a single institution.
  
  
  RESULTS
  HMII insertion was completed with the less invasive technique in all cases with no conversions to full sternotomy. There were no reoperations for bleeding and 70% of patients did not have any intraoperative blood product transfusion. No patient required right ventricular assist device support. Majority of patients (80%) were extubated by postoperative day 1. There were no wound, mediastinal or pocket infections. One patient suffered a new perioperative stroke. Median postoperative hospital stay was 19 days. Operative mortality was 7.5% and 12-month actuarial survival was 86 ± 6%.
  
  
  CONCLUSIONS
  Primary HMII implantation without median sternotomy is feasible and can be safely, effectively and routinely applied, using our less invasive approach. Further investigation is necessary to determine whether the non-invasive technique contributed to the low incidence of bleeding, blood transfusion, respiratory morbidity and right ventricular failure seen in this study.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY, USA anelechi.anyanwu@mountsinai.org anianyanwu@hotmail.com.
authors.forename: Anelechi C
authors.initials: AC
authors.lastname: Anyanwu
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY, USA.
authors.forename: Shinobu
authors.initials: S
authors.lastname: Itagaki
authors.affiliation: Transplant Cardiology, Mount Sinai Medical Center, New York, NY, USA.
authors.forename: Sean
authors.initials: S
authors.lastname: Pinney
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Adams
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006353:Heart-Assist Devices; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications; D012189:Retrospective Studies; D056346:Sternotomy
keywords: Blood transfusion; Left ventricular assist device; Minimally invasive surgery