Impact of Thoracotomy-Based Left Ventricular Assist Device Implantation on Right Ventricular Functional Preservation

Right ventricular (RV) dysfunction remains a critical determinant of outcomes following left ventricular assist device (LVAD) implantation. We used a doubly robust inverse probability weighting based on propensity scores to evaluate the association between surgical approach and clinical outcomes in 187 consecutive patients (thoracotomy: n = 55; sternotomy: n = 132). The primary endpoint was RV systolic function in the early postoperative period, assessed by tricuspid annular plane systolic excursion (TAPSE). Despite comparable baseline RV performance and hemodynamics, the thoracotomy-based approach was associated with superior preservation of postoperative RV systolic function compared to median sternotomy (TAPSE: 12.0 vs. 11.0 mm, p = 0.001). In weighted regression models, median sternotomy was associated with a significant reduction in postoperative TAPSE (β = -0.085, p = 0.036) and a 35% relative increase in hospital length of stay (p = 0.015). Furthermore, accounting for heart transplantation as a competing risk, median sternotomy was associated with a significantly higher hazard of long-term mortality (subdistribution hazard ratio [sHR]: 1.78, 95% confidence interval [CI]: 1.07-3.00, p = 0.027). These findings suggest that the clinical benefits of sternal-sparing techniques extend beyond acute functional protection. This surgical strategy supports the use of less invasive approaches to optimize both early recovery and long-term outcomes in the LVAD population.