Initial experience with non-thoracic, extraperitoneal, off-pump insertion of the Jarvik 2000 Heart in patients with previous median sternotomy

Background: Successful implantation of left ventricular assist devices (LVADs) in patients with previous median sternotomy remains challenging. Methods: Seven patients underwent implantation of a Jarvik 2000 Heart by an extrathoracic, extraperitoneal, sub-costal surgical approach, which allows easy exposure of the diaphragmatic surface of the heart and the supraceliac aorta. All patients were at very high risk and were receiving high doses of inotropic agents to maintain their cardiac function. All had undergone prior median sternotomy. We compared data for blood loss and intensive care unit (ICU) stay with those of 15 patients in whom the HeartMate I vented electric LVAD was placed through a re-do sternotomy incision. Results: All 7 patients survived the surgical procedure for implantation of the Jarvik 2000. All 7 patients were rapidly rehabilitated and had a short stay in the ICU (mean 3.3 days, range 1 to 8 days), as compared with the re-do HeartMate patients (mean 10.3 days, range 3 to 33 days). (p = 0.005). The average 12-hour blood loss was 635 ml in the Jarvik patients compared with 2,405 ml in the re-do HeartMate patients (p = 0.028). The cardiac index improved significantly in all Jarvik patients. Conclusions: The extrathoracic, extraperitoneal, sub-costal surgical approach is less invasive than a median sternotomy and allows the Jarvik 2000 to be implanted quickly and without cardiopulmonary bypass (CPB). By avoiding CPB and an extensive mediastinal dissection, bleeding is decreased in these hypocoagulable patients with compromised end-organ function. The decreased operative morbidity and mortality associated with this technique may allow consideration of the Jarvik 2000 Heart for safe and effective implantation in home-bound New York Heart Association (NYHA) Class III and IV patients.