Будущее кардиохирургии: малоинвазивная имплантация вспомогательных желудочковых устройств

Резюме

За последние 20 лет вспомогательные левожелудочковые устройства (LVAD) превратились из метода "терапии отчаяния" в плановый метод лечения терминальной сердечной недостаточности. В хирургии широко распространена тенденция к использованию менее инвазивных процедур. Как известно, уменьшение хирургической травмы снижает риск развития осложнений, связанных с большими разрезами, особенно обусловленных переливанием крови, или продолжительность госпитализации, и многие пациенты настаивают на использовании менее инвазивных методов. С 2014 г. при имплантации LVAD применяется в основном малоинвазивная техника. В настоящей статье рассмотрена "ганноверская техника", позволяющая хирургам во многим центрах во всем мире успешно применять малоинвазивнуо имплантацию LVAD.

Ключевые слова:левожелудочковое вспомогательное устройство (LVAD), малоинвазивный, имплантация, ганноверская техника

Финансирование. Исследование не имело спонсорской поддержки. 
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов. 
Вклад авторов. Авторы внесли равный вклад.
Для цитирования: Доган Г., Ханке Я.Х., Дениз Э., Мерзах А., Ли Т., Мариани С., Хаверих А., Шмитто Я.Д. Будущее кардиохирургии: малоинвазивная имплантация вспомогательных желудочковых устройств // Клиническая и экспериментальная хирургия. Журнал имени академика Б.В. Петровского. 2020. Т. 8, № 3. С. 17-20. DOI: https://doi.org/10.33029/2308-1198-2020-8-3-17-20 (англ.)

In the last twenty years, left ventricular Assist Devices (LVADs) have evolved from rescue to regular therapy in the treatment of terminal heart failure. In the past, devices were rather bulky and notwithstanding being life saving devices for many, the quality of life of the patients was severely impaired by heavy equipment and short battery capacity. The shift in strategy from pulsatile to continuous flow devices and consecutively from axial to centrifugal flow enabled engineers to decrease the size of the pump housings. While not being perfect devices, the current third generation of VAD has brought many innovations from bench to bedside such as artificial pulsatility, lighter equipment and extended battery capacities up to 18 hours resulting in increased survival rates as well of improved quality of life after VAD implantation.

A widespread trend in surgery is the use of less invasive procedures. The reduction of surgical trauma commonly reduces complications associated with large incisions especially blood transfusions or length of hospital stay. Additionally, many patients request less invasive procedures due to their cosmetically favorable results.

Lawrence Cohn was one of the pioneers in mini-mally-invasive cardiac surgery procedures. In the year 2009 and 2010 Prof. Schmitto had the honor to work with him during his stay at Harvard Medical School and was eager to learn new surgical techniques from him [1-3]. When Schmitto transitioned back to Germany to Hannover Medical School to work in the heart failure team with Prof. Martin Strueber, he was inspired to apply this knowledge to MCS surgery. Schmitto and Strueber started to brainstorm less invasive techniques for LVAD implantation and tested them eagerly in the animal laboratory. Ultimately, in 2011 we were successfully able to transfer the newly invented technique into human use.

The "Hannover Technique" for minimally-invasive LVAD implantation consists out of a hemi sternotomy combined with an anterolateral thoracotomy [4-11]. The original trick of this procedure is to tunnel the outflow graft intra-pericardially and spare a full sternotomy. Thus, the pericardium of the heart remains closed and there is no need to manipulate the position of the heart inside the thorax. Duirng the first years, this novel, innovative surgical technique faced a lot of criticism within the old conventional cardio-surgical world. Critiques said that the only benefit is sparing of the sternum, the risk of the minimal invasive procedure was initially declared to remain too high and the operation too difficult. However, only five-six years later, while gaining more and more experience at many different centers who where mainly trained in Hannover with this technique, the Hannover Team was able to show that there are indeed mayor benefits such as reduction of right heart failure and blood transfusions, the simplification of re-do procedures (including tunneling the outflow graft through the left pleural space) as well as a shorter in-hospital stay for patients after LVAD implantation.

Today, the Hannover Team successfully trained colleagues from all over the world in using the "Hannover Technique" and the technique successfully received CE mark (2016) as well as FDA approval (2018) for LVAD implantation. Therefore, the story of the "Hannover Technique" is an excellent example from bench to bedside implementation of a surgical technique which was being developed of Prof. Schmitto and Strueber's Team at Hannover Medical School (see figure).

The minially-invasive VAD-technique as described by Schmitto et al.

Example, in an actual issue of Artificial Organs two surgical centers describe their experiences with alternative LVAD implantation techniques. Ozer et. al from the department of cardiovascular surgery of the Kartal Kosuyolo Hospital in Istanbul, Turkey, present their experience with the transition from conventional technique to the less-invasive approach in left ventricular assist device surgery.

Kawabori et. al from the Division of Cardiotho-racic Transplant and Assist Devices from the Baylor College of Medicine in Houston, Texas, U.S.A. also report their experience of less invasive LVAD implantation technique as described by Schmitto at al. This group performed a retrospective study on eight patients who underwent LVAD implantation via a sternum sparing approach and outflow graft anastomosis to the descending aorta.

While both techniques impose a learning curve on surgeons, it is surely important to know about alternative techniques to conventional LVAD implantation and about their benefits to the patients [12-29]. Less-invasive LVAD implantation has become a standard in minimally-invasive and should be in the portfolio or every MCS surgeon. As shown in the article of Ozer et al. it is easily possible to transfer this technique into other programs with a steep learning curve. Anatomic variations like porcelain aorta or reoperative cases, challenging hemodynamics such as right heart failure or other challenges in LVAD surgery often require creative solutions. Therefore, it is important to be aware of alternative implantation techniques such as the anastomosis of the outflow graft to the descending aorta.

In the future, we will see many additional innovations in the design and function of ventricular assist devices. Pump miniaturization, transdermal power supply and improvements of hemocompatibility are suspected to even further improve outcomes and survival after VAD implantation. Thus, cardiac surgeons will continue to adapt implantation techniques to the new designs and possibly even further miniaturize VAD implantation.

References

1.    Schmitto J.D., Mokashi S.A., Cohn L.H. Minimally-invasive valve surgery. J Am Coll Cardiol. 2010; 56 (6): 455-62.

2.    Schmitto J.D., Mohr F.W., Cohn L.H. Minimally invasive aortic valve replacement: how does this perform in high-risk patients? Curr Opin Cardiol. 2011; 26 (2): 118-22.

3.    Schmitto J.D., Mokashi S.A., Cohn L.H. Past, present, and future of minimally invasive mitral valve surgery. J Heart Valve Dis. 2011; 20 (5): 493-8.

4.    Schmitto J.D., Molitoris U., Haverich A., Strue-ber M. Implantation of a centrifugal pump as a left ventricular assist device through a novel, minimized approach: upper hemisternotomy combined with anterolateral thoracotomy. J Thorac Cardiovasc Surg. 2012; 143 (2): 511-3.

5.    Schmitto J.D., Krabatsch T., Damme L., Netuka I. Less invasive HeartMate 3 left ventricular assist device implantation. J Thorac Dis. 2018; 10 (suppl 15): S1692-5.

6.    Chatterjee A., Mariani S., Hanke J.S., Li T., Mer-zah A.S., Wendl R., et al. Minimally invasive left ventricular assist device implantation: optimizing device design for this approach. Expert Rev Med Devices. 2020; Mar 2: 1-8. DOI:  https://doi.org/10.1080/17434440.2020.1735358

7.    Rojas S.V., Avsar M., Hanke J.S., Khalpey Z., Maltais S., Haverich A., et al. Minimally invasive ventricular assist device surgery. Artif Organs. 2015; 39 (6): 473-9.

8.    Rojas S.V., Avsar M., Uribarri A., Hanke J.S., Haverich A., Schmitto J.D. A new era of ventricular assist device surgery: less invasive procedures. Minerva Chir. 2015; 70 (1): 63-8.

9.    Maltais S., Anwer L.A., Tchantchaleishvili V., Ha-glund N.A., Dunlay S.M., Aaronson K.D., et al. Left lateral thoracotomy for centrifugal continuous-flow left ventricular assist device placement: an analysis from the mechanical circulatory support research network. ASAIO J. 2018; 64 (6): 715-20.

10.    Gummert J.F., Haverich A., Schmitto J.D., Potapov E., Schramm R., Falk V. Permanent implantable cardiac support systems. Dtsch Arztebl Int. 2019; 116 (50): 843-8.

11.    Feldmann C., Chatterjee A., Haverich A., Schmitto J.D. Left ventricular assist devices - a state of the art review. Adv Exp Med Biol. 2018; 1067: 287-94.

12.    Hanke J.S., Rojas S.V., Avsar M., Haverich A., Schmitto J.D. Minimally-invasive LVAD implantation: state of the art. Curr Cardiol Rev. 2015; 11 (3): 246-51.

13.    Schmitto J.D., Pya Y., Zimpfer D., Krabatsch T., Garbade J., Rao V., et al. Long-term evaluation of a fully magnetically levitated circulatory support device for advanced heart failure-two-year results from the HeartMate 3 CE Mark Study. Eur J Heart Fail. 2019; 21 (1): 90-7.

14.    Uriel N., Medvedofsky D., Imamura T., Maly J., Kruse E., Ivak P., et al. Echocardiographic changes in patients implanted with a fully magnetically levitated left ventricular assist device (HeartMate 3). J Card Fail. 2019; 25 (1): 36-43.

15.    Gustafsson F., Shaw S., Lavee J., Saeed D., Pya Y., Krabatsch T., et al. Six-month outcomes after treatment of advanced heart failure with a full magnetically levitated continuous flow left ventricular assist device: report from the ELEVATE registry. Eur Heart J. 2018; 39 (37): 3454-60.

16.    Netuka I., Sood P., Pya Y., Zimpfer D., Krabatsch T., Garbade J., et al. Fully magnetically levitated left ventricular assist system for treating advanced HF: a multicenter study. J Am Coll Cardiol. 2015; 66 (23): 2579-89.

17.    Schmitto J.D.,ZimpferD., Fiane A.E., LarbalestierR., Tsui S., Jansz P., et al. Long-term support of patients receiving a left ventricular assist device for advanced heart failure: a follow-up analysis of the Registry to Evaluate the HeartWare Left Ventricular Assist System. Eur J Cardio-thorac Surg. 2016; 50 (5): 834-8.

18.    Zimpfer D., Strueber M., Aigner P., Schmitto J.D., Fiane A.E., Larbalestier R., et al. Evaluation of the Heart-Ware ventricular assist device Lavare cycle in a particle image velocimetry model and in clinical practice. Eur J Cardiothorac Surg. 2016; 50 (5): 839-48.

19.    Schmitto J.D., Rojas S.V., Haverich A. Left ventricular assist devices for advanced heart failure. N Engl J Med. 2017; 376 (19): 1894.

20.    Feldmann C., Chatterjee A., Hanke J.S., Dogan G., Haverich A., Schmitto J.D. Novel centrifugal pump for heart failure patients: initial success and future challenges. J Thorac Dis. 2017; 9 (6): 1429-31.

21.    Schmitto J.D., Hanke J.S., Rojas S.V., Avsar M., Haverich A. First implantation in man of a new magnetically levitated left ventricular assist device (HeartMate III). J Heart Lung Transplant. 2015; 34 (6): 858-60.

22.    Schmitto J.D., Hanke J.S., Rojas S., Avsar M., Ma-lehsa D., Bara C., et al. Circulatory support exceeding five years with a continuous-flow left ventricular assist device for advanced heart failure patients. J Cardiothorac Surg. 2015; 10: 107.

23.    Schmitto J.D., Rojas S.V., Hanke J.S., Avsar M., Haverich A. Minimally invasive left ventricular assist device explantation after cardiac recovery: surgical technical considerations. Artif Organs. 2014; 38 (6): 507-10.

24.    Schmitto J.D., Avsar M., Haverich A. Increase in left ventricular assist device thrombosis. N Engl J Med. 2014; 370 (15): 1463-4.

25.    Schmitto J.D., Pya Y., Zimpfer D., Krabatsch T., Garbade J., Rao V., et al. Long-term evaluation of a fully magnetically levitated circulatory support device for advanced heart failure-two-year results from the HeartMate 3 CE Mark Study. Eur J Heart Fail. 2019; 21 (1): 90-7.

26.    Schmitto J.D., Zimpfer D., Fiane A.E., et al. Longterm support of patients receiving a left ventricular assist device for advanced heart failure: a follow-up analysis of the Registry to Evaluate the HeartWare Left Ventricular Assist System. Eur J Cardiothorac Surg. 2016; 50 (5): 834-8.

27.    Hanke J.S., Riebandt J., Wahabzada M., Nur F., Wahabzada A., Dogan G., et al. Driving After Left Ventricular Assist Device Implantation. Artif Organs. 2018; 42 (7): 695-9.

28.    Schmitto J.D., Hanke J.S., Rojas S.V., Avsar M., Haverich A. First implantation in man of a new magnetically levitated left ventricular assist device (HeartMate III). J Heart Lung Transplant. 2015; 34 (6): 858-60.

29.    Schmitto J.D., Pya Y., Zimpfer D., Krabatsch T., Garbade J., Rao V., et al. Long-term evaluation of a fully magnetically levitated circulatory support device for advanced heart failure-two-year results from the HeartMate 3 CE Mark Study. Eur J Heart Fail. 2019; 21 (1): 90-7.