Clinical experience with sternotomy versus subcostal approach for exchange of the HeartMate XVE to the HeartMate II ventricular assist device

Background. Most patients undergoing destination therapy with a HeartMate XVE left ventricular assist device will eventually require pump exchange to continue long-term cardiac support. Methods. To determine whether left ventricular assist device exchange can be accomplished with low morbidity and mortality, we retrospectively reviewed the records of 14 patients who experienced pump malfunction and subsequently required replacement of their HeartMate XVE left ventricular assist devices with HeartMate II axial-flow pumps. We collected data regarding duration of support and reasons for pump failure, perioperative characteristics, and operative approach. Results. On average, patients were supported 473 +/- 233 days with HeartMate XVE pumps. Seven early patients required both subcostal and sternotomy incisions; 7 later patients had subcostal incisions only. Thirteen patients underwent successful exchange to the HeartMate II; 1 patient died in the operating room. Another patient died in the perioperative period (30-day mortality, 14% [2 of 14]). There were significant differences between the two groups. The patients who required only subcostal incisions had shorter operative times (187 versus 220 minutes; p=0.04) and required fewer transfused blood products (packed red blood cells, 8.6 versus 28.7 units; p=0.03; and fresh-frozen plasma, 12.4 versus 30.9 units; p=0.04). Additionally, the patients with subcostal incisions had shorter postoperative intensive care unit stays (5.3 +/- 1.1 versus 8.4 +/- 3.1 days for redo sternotomy patients; p=0.03). Of the survivors, average hospital stay was 22 +/- 14 days. Average long-term follow-up was 11.2 +/- 7.8 months; 71% (10 of 14) of patients are currently alive. Conclusions. Exchange of a HeartMate XVE to a HeartMate II can be accomplished with relatively low morbidity and mortality through a subcostal approach.