Division of Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada.
Critical Care and Medicine Departments and Li Ka Shing Knowledge Institute, St. Michael's Hospital, and Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
J Heart Lung Transplant. 2022 Oct;41(10):1440-1458. doi: 10.1016/j.healun.2022.07.006. Epub 2022 Jul 11.
Left ventricular assist device (LVAD) implantation via lateral thoracotomy can offer similar effectiveness to conventional approaches with less perioperative adverse events. We performed a systematic review and meta-analysis to determine the potential benefits of lateral thoracotomy (LT) for LVAD implantation compared to median sternotomy.
We searched MEDLINE and Embase databases for studies comparing continuous-flow LVAD implantation using LT with conventional sternotomy. Main outcomes were perioperative mortality and complications.
Twenty-five observational studies enrolling 3072 patients were included with a median follow-up of 10 months. Perioperative mortality (30 day or in-hospital) was 7% (LT) and 14% (sternotomy); however, mortality differences were no longer statistically significant in matched/adjusted studies (RR:0.86; 95%CI:0.52-1.44; p = 0.58). LT was associated with decreased need for blood product transfusions (mean difference[MD]: -4.7; 95%CI: -7.2 to -2.3 units; p < 0.001), reoperation for bleeding (RR:0.34; 95%CI:0.22-0.54; p < 0.001), postoperative RVAD implantation (RR:0.53; 95%CI:0.36-0.77; p < 0.001), days requiring inotropes (MD: -1.1; 95%CI: -2.1 to -0.03 inotrope days; p = 0.04), ICU (MD: -3.3; 95%CI: -6.0 to -0.7 ICU days; p = 0.01), and hospital length of stay (MD: -5.1; 95%CI: -10.1 to -0.1 hospital days; p = 0.04) in matched/adjusted studies. Overall mortality during follow-up was significantly lower for LT in unmatched/unadjusted studies but not statistically significantly lower in matched/adjusted studies (Hazard Ratio:0.82; 95%CI:0.59-1.14; p = 0.24).
LVAD implantation via LT was associated with significantly decreased need for blood products, reoperation for bleeding, and postoperative RVAD implantation. Furthermore, days on inotropic support were also lower, likely contributing to the shorter length of stay. These findings support greater use of a LT approach for carefully selected patients.
通过侧胸切开术植入左心室辅助装置（LVAD）可以提供与传统方法相似的效果，同时减少围手术期不良事件。我们进行了一项系统回顾和荟萃分析，以确定与正中胸骨切开术相比，通过侧胸切开术（LT）植入 LVAD 的潜在益处。
我们在 MEDLINE 和 Embase 数据库中搜索了比较使用 LT 与传统胸骨切开术植入连续流 LVAD 的研究。主要结果是围手术期死亡率和并发症。
共有 25 项观察性研究纳入了 3072 名患者，中位随访时间为 10 个月。围手术期死亡率（30 天或住院期间）为 7%（LT）和 14%（胸骨切开术）；然而，在匹配/调整后的研究中，死亡率差异不再具有统计学意义（RR：0.86；95%CI：0.52-1.44；p=0.58）。LT 与减少血液制品的需求相关（平均差值[MD]：-4.7；95%CI：-7.2 至 -2.3 单位；p<0.001），需要再次手术治疗出血（RR：0.34；95%CI：0.22-0.54；p<0.001），术后 RVAD 植入（RR：0.53；95%CI：0.36-0.77；p<0.001），需要使用正性肌力药物的天数（MD：-1.1；95%CI：-2.1 至 -0.03 正性肌力药物天数；p=0.04），ICU 天数（MD：-3.3；95%CI：-6.0 至 -0.7 ICU 天数；p=0.01）和住院天数（MD：-5.1；95%CI：-10.1 至 -0.1 住院天数；p=0.04）在匹配/调整后的研究中。在未匹配/未调整的研究中，LT 组的总死亡率明显较低，但在匹配/调整后的研究中，这一差异没有统计学意义（风险比：0.82；95%CI：0.59-1.14；p=0.24）。
通过 LT 植入 LVAD 与血液制品需求、出血再手术和术后 RVAD 植入的需求显著降低有关。此外，正性肌力药物的使用天数也较低，这可能导致住院时间缩短。这些发现支持在精心挑选的患者中更多地使用 LT 方法。
