Commentary: Sometimes there is a simpler route!

Central MessageLeft axillary–right axillary outflow tract grafting for left ventricular assist device implantation is feasible; simpler or more reproducible options should be considered for high-risk patients.See Article page 197. Left axillary–right axillary outflow tract grafting for left ventricular assist device implantation is feasible; simpler or more reproducible options should be considered for high-risk patients. See Article page 197. Left ventricular assist device (LVAD) implantation is an established treatment modality for patients with terminal heart failure. Correct positioning of the outflow-graft is one of the key factors for determining the long-term outcome of patients.1Adamson R.M. Mangi A.A. Kormos R.L. Farrar D.J. Dembitsky W.P. Principles of HeartMate II implantation to avoid pump malposition and migration.J Card Surg. 2015; 30: 296-299Crossref PubMed Scopus (43) Google Scholar Graft malposition can increase turbulence, effect pump performance, and increase subsequent risk of pump thrombosis or cerebrovascular complications.2Schmitto J.D. Avsar M. Haverich A. Increase in left ventricular assist device thrombosis.N Engl J Med. 2014; 370: 1463-1464Crossref PubMed Scopus (9) Google Scholar,3Benk C. Mauch A. Beyersdorf F. Klemm R. Russe M. Blanke P. et al.Effect of cannula position in the thoracic aorta with continuous left ventricular support: four-dimensional flow-sensitive magnetic resonance imaging in an in vitro model.Eur J Cardiothorac Surg. 2013; 44: 551-558Crossref PubMed Scopus (18) Google Scholar The main site of outflow graft placement, the ascending aorta, has been widely studied.4Aliseda A. Chivukula V.K. McGah P. Prisco A.R. Beckman J.A. Garcia G.J. et al.LVAD outflow graft angle and thrombosis risk.ASAIO J. 2017; 63: 14-23Crossref PubMed Scopus (34) Google Scholar Advancements in alternative implant strategies, combined with miniaturization of the technology, have broadened the strategy for outflow graft placement to major arteries such as the descending aorta, the innominate, the subclavian, or even the axillary artery.5Doersch K.M. Tong C.W. Gongora E. Konda S. Sareyyupoglu B. Temporary left ventricular assist device through an axillary access is a promising approach to improve outcomes in refractory cardiogenic shock patients.ASAIO J. 2015; 61: 253-258Crossref PubMed Scopus (11) Google Scholar, 6Makdisi G. Wang I.W. Minimally invasive is the future of left ventricular assist device implantation.J Thorac Dis. 2015; 7: E283-E288PubMed Google Scholar, 7Maltais S. Davis M.E. Haglund N. Minimally invasive and alternative approaches for long-term LVAD placement: the Vanderbilt strategy.Ann Cardiothorac Surg. 2014; 3: 563-569PubMed Google Scholar, 8El-Sayed Ahmed M.M. Aftab M. Singh S.K. Mallidi H.R. Frazier O.H. Left ventricular assist device outflow graft: alternative sites.Ann Cardiothorac Surg. 2014; 3: 541-545PubMed Google Scholar In this issue of the Journal, Tucker and colleagues9Tucker D.L. Perry J. Bock A. Douglas A. Albert C. Kirksey L. et al.Left ventricular assist device implantation with axillary–axillary outflow graft.J Thorac Cardiovasc Surg Tech. 2020; 4: 197-199Google Scholar report the results of LVAD implantation with a novel alternative approach, the left axillary–right axillary arterial bypass (LARAAB) graft. In a minimally invasive setting, LARAAB was performed in a patient with a history of ischemic cardiomyopathy who underwent LVAD implantation for cardiogenic shock. The peculiarity of the described case lies in the fact that the previously placed outflow graft on the left axillary artery did not result in postoperative hemodynamic improvement whereas there was no notable anatomic obstruction. The patient required increasing vasopressor support caused by insufficient LVAD outflow and decision for reoperation was made. During reconstruction, the LVAD did not tolerate partial side clamping, and no anastomotic reconstruction on the graft itself could have been made, and this variant, LARAAB, was performed. The Latin proverb Aut viam inveniam aut faciam (“I shall either find a way or make one”) appropriately describes the authors' creative ability to tackle this case, and the authors further opt LARAAB to be a feasible treatment strategy in case of porcelain ascending aorta, unattainable descending aorta, and small calibre axillary artery. Although this creative strategy can potentially be of additive value in the armamentarium of the cardiothoracic surgeon, several issues can arise, and we question the need for such an extension of a previously described strategy. When do we stop and plan a standard sternotomy intervention, refer the patient for greater-risk heart transplantation, or simply do not offer the LVAD intervention? What is the long-term outcome of such a strategy? If this technique is applicable in specific patients, how should we determine the right patient for this strategy? New complications will occur, especially with 2 grafts. In the postoperative low-output setting, how would we preoperatively adequately identify the culprit in case of LARAAB? Little is known about optimal placement, metric, rheology of flow, and appropriate dimensions of the graft for optimal postoperative hemodynamic results. The availability of multiple alternative surgical techniques in the armamentarium of the surgeon requires careful tailoring to the need of the patient. While the presented LARAAB intervention was performed with success, we caution our surgical community to start widely applying this technique and to look for other options. Sometimes there is a simpler route to help the cat get some milk. Left ventricular assist device implantation with axillary–axillary outflow graftJTCVS TechniquesVol. 4PreviewLeft ventricular assist devices (LVADs) are used for patients with end-stage heart disease either as a bridge to transplant or as destination therapy. Although the most common configuration is LV apex to ascending aorta through a sternotomy, patient anatomy and clinical circumstances may necessitate alternative configurations.1 Herein, we describe a novel alternative approach to augment LVAD flow with a left axillary–right axillary arterial bypass graft (LARAAB). Full-Text PDF Open Access

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