Thoracotomy Versus Sternotomy for Left Ventricular Assist Device Placement: A Statewide Multicenter Analysis

Background:This study aimed to evaluate short-term outcomes, trends, and statewide practice patterns for thoracotomy left ventricular assist device (T-LVAD) versus sternotomy left ventricular assist device (S-LVAD) implantation.Methods:Adult patients who underwent durable LVAD implantation (7/1/2014–12/31/2024) within a regional collaborative were identified and stratified by surgical approach. Patients who received a planned right ventricular assist device (RVAD) or other intraoperative right-heart support devices were excluded. Univariable and multivariable analyses were performed to compare 30-day outcomes.Results:Among 770 patients, 88 (11.4%) underwent T-LVAD. Notably, T-LVAD patients were older (62 vs. 57 years; p = 0.014), more likely to be Caucasian (66% vs. 55%; p = 0.049), had a higher body mass index (BMI) (30 vs. 28; p = 0.009), and had more cerebrovascular disease (32% vs. 21%; p = 0.019) but less chronic lung disease (42% vs. 54%; p = 0.031) compared with S-LVAD patients. A total of 61.4% of T-LVAD procedures were redo operations. T-LVAD patients underwent fewer concomitant procedures (1.1% vs. 38.9%; p < 0.001), experienced less postoperative atrial fibrillation (8.0% vs. 23%; p = 0.001), had shorter intensive care unit stays (124 vs. 209 hours; p < 0.001) and postoperative lengths of stay (15 vs. 22 days; p < 0.001), and incurred lower hospitalization costs (USD 198,978 vs. USD 267,785; p < 0.001). Operating room time (343 vs. 361 min; p = 0.165), postoperative right heart failure (2.3% vs. 1.2%; p = 0.32), readmission (33% vs. 26%; p = 0.153), and operative mortality (4.5% vs. 9.5%; p = 0.123) were comparable between groups. After risk adjustment, T-LVAD remained associated with lower hospitalization costs (USD –58,415.69, standard error (SE) 20,627.72; p = 0.005).Conclusions:T-LVAD was associated with lower postoperative morbidity and reduced resource utilization compared with S-LVAD. The use of T-LVAD remains an important option, is noninferior to S-LVAD, and may be associated with a more benign postoperative course.