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Background Historically, obesity was considered a relative contraindication to left ventricular assist device (LVAD) implantation with less invasive surgery (LIS). The present study aimed to compare the outcomes of obese patients who underwent LVAD implantation through LIS with those who received full sternotomy (FS) implantation. Methods We retrospectively reviewed all patients implanted with HeartMate 3 LVAD in our institution between September 2015 and June 2020. Obese patients (BMI ≥ 30 kg/m2 ) were included and dichotomized based on surgical approach into the FS or LIS cohort. Results Of 231 implanted patients, 107 (46%) were obese and included in the study. FS was performed in 26 (24%) patients and LIS approach in 81 (76%) patients. Preoperative patient characteristics were similar between the cohorts. Postoperatively, patients in LIS cohort had less bleeding (p = 0.029), fewer transfusions (p = 0.042), shorter duration of inotropic support ( p = 0.049), and decreased incidence of severe RV failure (11.1% vs 30.8%, p = 0.028). Survival to discharge for the obese population was 87.5% overall and did not differ based on an approach (91.4% LIS vs 76.9% FS, p = 0.079). More LIS patients were discharged home (60.0% vs 82.4%, p = 0.041) rather than to rehabilitation center . Conclusion Our results showed that the LIS approach in obese patients is associated with fewer postoperative complications and a trend towards better short-term survival. These results suggest that less invasive LVAD implantation is a safe and effective approach for obese patients. Future prospective randomized trials are required to substantiate these results.

Purpose Right ventricular failure (RVF) remains one of the major cause of morbidity and mortality after left ventricular assist device (LVAD) surgery. The purpose of this study was to investigate the incidence of RVF after less invasive surgery (LIS) LVAD surgery compared to median sternotomy. Methods The study population comprised of 231 patients who underwent HeartMate 3 LVAD implantation in our institution between September 2015 and June 2020. Patients were compared based on surgical approach: full sternotomy (FS) or LIS. The primary outcome was RVF as defined by INTERMACS. Index hospitalization major complications and survival were secondary outcomes. Results LIS approach was used in 161 (69.7%) patients and FS approach in 70 (30.3%) of our LVAD patients. Baseline patient characteristics were similar between cohorts apart from LIS patients being younger (54±14 vs 60±11, p= 0.003). Postoperatively, LIS patients had decreased postoperative bleeding (p=0.001) and shorter time on mechanical ventilation (p Conclusion Less invasive LVAD implantation is associated with improved perioperative outcomes compared to median sternotomy, including a lower incidence of severe right heart failure and need for temporary mechanical circulatory support. Further research is needed to elucidate the mechanism of the less invasive approach in preserving RV function.

Purpose We sought to develop and implement a comprehensive enhanced recovery after surgery protocol for patients implanted with left ventricular assist device. Methods Our approach to the development and phased implementation of the ERAS protocol were described (Figure 1). We retrospectively reviewed prospectively collected LVAD implant data at our institution between February 2019 and August 2020. Patients were divided into 6-months period cohorts: Pre-ERAS cohort (which covered 6 months prior to ERAS initiation) and ERAS cohort. A time gap of 6 months between the cohorts was used to appreciate initial outcomes after implementing most of the protocol phases. Results Of the 115 LVAD implants, 38 patients were classified in pre-ERAS cohort and 46 in ERAS cohort. We reduced transfusions and discharge on opioids and show a trend towards reduced intubation times, ICU and overall length of stay (Table 1). Conclusion ERAS for advanced heart failure patients deemed candidates for LVAD therapy is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. We described details of the protocol, challenges faced as well as early positive changes in clinical outcomes. Further studies are needed to both assess provider satisfaction and evaluate benefits of an ERAS protocol in reduction of adverse events.

Purpose The present study aimed to compare the outcomes of obese patients who underwent HeartMate 3 implantation through less invasive surgery (LIS) with those who received full sternotomy (FS) implantation. We hypothesized that LIS is a safe and effective technique for LVAD implantation in obese patients. Methods We performed a retrospective review of all patients implanted with HeartMate 3 LVAD in our institution from September 2015 through Jun 2020. Obese patients (BMI≥ 30 kg/m2) were included in the study and dichotomized based on surgical approach into the full sternotomy (FS) cohort or LIS. Primary outcomes were index hospitalization and 30-day survival. Secondary outcomes were incidence of index hospitalization major complications. Results Of 231 patients implanted patients, 107 (46.3%) were obese and included in the study. FS was used in 26 (24.3%) patients and LIS approach in 81 (75.7%) patients. Preoperative patient characteristics were similar between the cohorts (Table 1). In the immediate postoperative course, fewer patients in the LIS cohort received units of packed red blood cells (34.6% vs 57.7%, p=0.042) and fresh frozen plasma (19.8 vs 46.2%, p=0.011). Duration of postoperative inotropic support was shorter in LIS cohort (p=0.049). The incidence of major complications was similar between the groups. Decreased incidence of severe RV failure (30.8% vs 11.1% LIS, p=0.028) and need for RVAD implantation (p=0.037) were observed in LIS cohort. Survival to discharge for the obese population was 87.5% overall and did not differ based on an approach (76.9% FS vs 91.4% LIS, p=0.079). Conclusion These data demonstrate multiple potential benefits of the less invasive surgical technique, including fewer postoperative complications and a trend towards better survival to discharge. This study suggests that less invasive HeartMate 3 implantation is a safe and effective approach for obese patients. Future prospective randomized trials are required to confirm our data.

Purpose The purpose of the present study is to examine the effect of operative time of day on outcomes in orthotopic heart transplant (OHT) recipients. We hypothesized that nighttime OHT operations would be associated with increased 1-year mortality when compared to daytime OHT operations. Methods We performed a retrospective analysis of adult heart transplant recipients in the United Network for Organ Sharing (UNOS) database from January 2000 to December 2019. Operative time of day was derived from the donor cross-clamp time (night, 6 pm-4 am; day, 4 am-6 pm). The primary outcome was survival at 1 year. Kaplan-Meier curves and log-rank statistics were generated to compare the effect of operative time and were further stratified by age, transplant center yearly volume (low volume, Results Of the 42,007 patients included in the study, 24,200 (57.6%) underwent nighttime and 17,807 (42.4%) daytime OHT (Table 1). Preoperative patient characteristics were similar between cohorts. 1-year survival (Figures 1) was not different between the cohorts (89.7 vs 89.5%, p=0.630). When further stratified by age, center volume, or VAD status, 1-year survival between operative times still remained insignificant. Conclusion There is no significant association between nighttime operations and 1-year post-transplant survival in adult heart transplant recipients.