Complete Sternal-Sparing Technique Improves Outcomes and Decreases RV Failure Compared to Re-Operative Sternotomy

Purpose Patients with a history of previous sternotomy often pose difficult surgical challenges for subsequent cardiac procedures. We hypothesized that the less invasive complete sternal-sparing approach would demonstrate favorable outcomes compared to full sternotomy (FS) for patients with a history of previous sternotomy. Methods We retrospectively reviewed all patients implanted with a HeartMate 3 (HM3) at our institution from September 2017 through September 2018 (n=63). Patients were included if they had history of prior sternotomy and separated into groups based on LVAD implantation technique: CSS versus re-operative sternotomy. Preoperative characteristics and postoperative outcomes were compared between cohorts. Results Of the 17 (30%) HM3 patients with a history of previous sternotomy, 10 (59%) were implanted via CSS and 7 (41%) by re-operative sternotomy. The CSS cohort tended to be older (65±6 vs 56±11 years, p = 0.055) and more likely to have undergone CABG (80% vs 14%, p = 0.015) while the FS cohort was more likely to have undergone previous aortic valve replacement (71% vs 10%, p = 0.035) (Table). The CSS cohort demonstrated fewer overall complications (30% vs 86%, p = 0.050) including a decreased incidence of severe right ventricular failure (0% vs 57%, p = 0.015). There was a trend towards shorter ICU length of stay (median, [IQR]; 4 [3-6] vs 14 [4.5-32] days, p = 0.218), total hospital length of stay (13 [12-24] vs 32.5 [20.5-61.5] days, p = 0.104) and improved 30-day survival (90% vs 57%, p = 0.250) in the CSS cohort. Conclusion LVAD implantation via CSS approach demonstrates fewer complications and decreased incidence of severe right ventricular failure in patients undergoing re-operative cardiac surgery. The CSS approach is our preferred surgical implantation technique for this patient population.