title: Improved early survival with a nonsternotomy approach for continuous-flow left ventricular assist device replacement.
abstract: BACKGROUND
  Even in the modern era of continuous-flow left ventricular assist devices (CF LVADs), device replacement may be required. Nonsternotomy (NS) approaches are being used more commonly for replacement procedures. Outcomes after this less invasive approach compared with those after a reoperative sternotomy (RS) have not been extensively studied. Furthermore, the clinical impact of concurrent cardiac procedures during device replacement has not been examined.
  
  
  METHODS
  From 2005 to 2013, all consecutive implantable LVAD procedures were reviewed, and those using CF devices as both the initial and replacement device were identified. These CF LVAD replacement procedures were divided into those using an RS and those using an NS approach. Periprocedural morbidity and mortality were compared between the groups.
  
  
  RESULTS
  A total of 42 CF LVAD replacements were performed in 39 patients, with 20 using an RS approach and 22 using an NS approach. Eleven of the 20 replacement procedures performed by RS included a concurrent cardiac procedure. Relative to the RS cohort, the NS approach was associated with shorter cardiopulmonary bypass time, reduced length of mechanical ventilation, decreased transfusion requirements, less inotropic support, decreased incidence of right ventricular (RV) dysfunction, and shorter intensive care unit (ICU) and overall hospital stays. An NS approach was also associated with improved 30- and 90-day survival (100% versus 79.0% in the RS group; p = 0.048). RS replacement procedures appeared to be associated with increased morbidity, regardless of whether they included concurrent cardiac procedures.
  
  
  CONCLUSIONS
  Patients who did not require an RS approach and who underwent CF LVAD replacement through an NS approach had improved survival and reduced morbidity compared with those who required an RS.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Schechter
authors.affiliation: Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Chetan B
authors.initials: CB
authors.lastname: Patel
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Blue
authors.affiliation: Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
authors.forename: Ian
authors.initials: I
authors.lastname: Welsby
authors.affiliation: Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Joseph G
authors.initials: JG
authors.lastname: Rogers
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Jacob N
authors.initials: JN
authors.lastname: Schroder
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina. Electronic address: milan002@mc.duke.edu.
authors.forename: Carmelo A
authors.initials: CA
authors.lastname: Milano
mesh_terms: D005260:Female; D006333:Heart Failure / Q000401:mortality* / Q000601:surgery*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery; D011475:Prosthesis Failure; D019919:Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D012086:Reoperation; D012189:Retrospective Studies; D056346:Sternotomy; D015996:Survival Rate; D013997:Time Factors