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. 2025 Mar 22:8:100256.
doi: 10.1016/j.jhlto.2025.100256. eCollection 2025 May.

The approach to placement of a continuous-flow intracorporeal ventricular assist device in small left ventricle

Ryaan El-Andari  1 , Josiane Dion  2 , Jennifer Conway  3 , Tara Pidborochynski  3 , Lindsey Carter  2 , Gurmeet Singh  1   4 , Roderick MacArthur  1 , Steven Meyer  1 , Devilliers Jonker  5 , Darren H Freed  5 , Holger Buchholz  1
Affiliations

The approach to placement of a continuous-flow intracorporeal ventricular assist device in small left ventricle

Ryaan El-Andari et al. JHLT Open. .

Abstract

Background: The HeartMate 3 (HM3) has become among the most widely utilized durable left ventricular (LV) assist devices (LVAD) owing to reduced rates of pump thrombosis, bleeding, and stroke. One limitation of the HM3 is its large size, which poses a challenge for implantation in smaller LVs. Herein, we describe a novel technique for durable LVAD implantation in patients with a small LV.

Methods: Patients who underwent durable LVAD implantation from January 2020 to August 2024 were included in this study. The modified technique involved excision of the mitral valve (MV) and associated apparatus to create room for the LVAD inflow. The primary outcome was mortality, and secondary outcomes included rates of postoperative complications and hemodynamic parameters. Patient follow-up was until September 2024.

Results: Eleven patients were included in this study. All patients received an HM3. The median preoperative LV end-diastolic diameter was 5.1 cm. The median total time on LVAD was 149 days, and overall mortality was 27.2% occurring a median of 204 days post-LVAD implantation. Four patients (36.4%) underwent heart transplantation and 4 (36.4%) were alive on LVAD at last follow-up. Proportions of morbidity included readmission for heart failure (n = 2, 18.2%), cerebrovascular accident (n = 2, 18.2%), and pump thrombosis (n = 0).

Conclusions: The small LV has been a significant challenge for durable LVAD insertion and is often considered a contraindication. A modified approach to LVAD insertion, including excision of the MV and associated apparatus and alignment of the LVAD inflow cannula with the MV orifice, allows for LVAD implantation in patients with a small LV.

Keywords: heart failure; left ventricle; mechanical circulatory support; mitral valve; ventricular assist device.

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Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Holger Buchholz reports a relationship with Abbott that includes consulting or advisory. Jennifer Conway reports a relationship with Abbott that includes funding grants. Jennifer Conway: medical monitor of the Pumpkin Trial. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgments and Funding: None.

Figures

Figure 1
Figure 1
Illustrations of the surgical technique for mitral valvectomy and durable left ventricular assist device implantation. (A) Shows the cardiac anatomy before surgery, (B) illustrates the apical incision, (C) illustrates the left heart after mitral valvectomy, and (D) shows the implanted left ventricular assist device in the ventricle pointed toward the mitral valve orifice.
Figure 2
Figure 2
Post-LVAD implantation echocardiogram demonstrating a closed aortic valve during diastole with no aortic insufficiency (A) and the excised mitral valve during systole with no retrograde flow across the mitral valve (B). LVAD, left ventricular assist devices.
Figure 3
Figure 3
Median pulmonary artery pressures (mm Hg) (A) and pulmonary vascular resistance (dyn/s/cm−5) (B) measured preoperatively and at 1 year post-LVAD implantation. LVAD, left ventricular assist device.
See this image and copyright information in PMC

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