Left ventricular assist device outflow graft: alternative sites

We describe three alternative approaches for the left ventricular assist device (LVAD) outflow graft during implantation of the LVAD. The supraceliac abdominal aorta, innominate artery and left axillary artery were employed as alternative sites for the LVAD outflow graft in the setting of a heavily calcified ascending aorta or a hostile chest wall and mediastinum. The first approach involved the use of the supraceliac abdominal aorta. Given that the patient had a history of multiple previous breast surgeries and chest wall radiation for breast cancer treatment, a left subcostal incision was employed as a sternotomy-sparing approach. The second approach was the use of the innominate artery in a patient with a porcelain ascending aorta. The patient underwent pulmonary valve replacement, right ventricle outflow tract reconstruction and tricuspid valve annuloplasty in addition to the LVAD implantation. The third approach was the use of the left axillary artery. This patient had a history of LVAD implantation and subsequently developed infection with pseudoaneurysm formation at the aortic anastomosis of the outflow graft. We conclude that the supraceliac abdominal aorta, the innominate artery and the left axillary artery are potential alternative routes for the LVAD outflow graft in the settings of heavily calcified ascending aorta or a hostile chest wall and mediastinum. Although the described alternative approaches are safe and viable options, we highly recommend utilizing these approaches only in selected patients with significantly higher risks and hazards to the standard surgical approach.