Department of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, New York, USA.
Samuel J. Wood Library and CV Starr Biomedical Information Centre Weill Cornell Medicine, New York, New York, USA.
J Card Surg. 2021 Jul;36(7):2314-2328. doi: 10.1111/jocs.15552. Epub 2021 Apr 27.
Thoracotomy approaches to left ventricular assist device (LVAD) implantation may reduce surgical morbidity and, through preservation of the pericardial restraint over the right heart, may reduce the incidence of right ventricular failure (RVF).
A meta-analysis of all original studies describing the effect of the surgical approach on postoperative outcomes after LVAD implantation was performed. Postoperative outcomes analyzed.
Thirteen studies were included with 692 patients undergoing a sternotomy and 373 a thoracotomy approach. Patients undergoing a thoracotomy approach had a higher comorbid status (INTERMACS 1-2: 56% vs. 44%; p = .0004), but were less likely to undergo a concomitant procedure (4% vs. 15%; p = .0002) than patients undergoing a sternotomy approach. Patients undergoing a thoracotomy approach demonstrated a reduced incidence of RVF (OR, .47; CI, .23-.97; p = .04), reexploration for bleeding (OR, .55; CI, .32-.94; p = .03), perioperative blood transfusion (SMD, -.30; CI, -.49 to -.11; p = .002), LOS (-5.57; -10.56 to -.59; p = .03), and mortality (OR, .57; CI, .33-.98; p = .04), but no difference in RVAD requirement or stroke were noted. Metaregression demonstrated that the performance of a concomitant procedure did not modify the effect of the surgical approach on the primary endpoints of RVF or RVAD requirement.
In the current meta-analysis including over 1000 patients undergoing LVAD implantation, a thoracotomy approach was associated with a reduced incidence of RVF (but not RVAD requirement), bleeding, LOS, and mortality. No difference in stroke rates was noted. These findings not only offer additional support as to the feasibility of a thoracotomy approach for LVAD implantation but also suggest a potential superiority over a sternotomy approach.
经胸入路左心室辅助装置（LVAD）植入术可降低手术发病率，并且通过保留心包对右心的限制，可能降低右心室衰竭（RVF）的发生率。
对所有描述 LVAD 植入术后手术入路对术后结果影响的原始研究进行荟萃分析。分析术后结果。
共纳入 13 项研究，其中 692 例患者行胸骨切开术，373 例患者行剖胸术。行剖胸术的患者合并症发生率更高（INTERMACS 1-2：56% vs. 44%；p=0.0004），但与行胸骨切开术的患者相比，行剖胸术的患者更不可能同时进行其他手术（4% vs. 15%；p=0.0002）。行剖胸术的患者 RVF 发生率降低（OR，0.47；95%CI，0.23-0.97；p=0.04），再探查出血（OR，0.55；95%CI，0.32-0.94；p=0.03），围手术期输血（SMD，-0.30；95%CI，-0.49 至 -0.11；p=0.002），住院时间（-5.57；-10.56 至 -0.59；p=0.03）和死亡率（OR，0.57；95%CI，0.33-0.98；p=0.04）降低，但 RVAD 需求或中风无差异。荟萃回归表明，同时进行其他手术并不会改变手术入路对 RVF 或 RVAD 需求的主要终点的影响。
在目前包括 1000 多例接受 LVAD 植入术的患者的荟萃分析中，剖胸术与 RVF（但不是 RVAD 需求）、出血、住院时间和死亡率降低相关。中风发生率无差异。这些发现不仅为剖胸术用于 LVAD 植入术的可行性提供了更多支持，而且还表明其可能优于胸骨切开术。
