On Oct. 3, Shaun Ott made a bit of medical history. Surgeons at UCHealth University of Colorado Hospital implanted a HeartMate 3, a pump that helps Ott’s failing heart drive blood to his body’s oxygen-starved organs. The news wasn’t so much what Ott’s surgeons did, but how they did it.

The HeartMate 3 is the latest in a line of left ventricular assist devices (LVADs), approved for use by the FDA in late August for heart failure patients like Ott, 52, as a bridge to a heart transplant. In all other procedures in the United States prior to Ott’s, surgeons had implanted the HeartMate 3 by opening the patient’s sternum with an approximately 12-inch incision to expose the left ventricle and aorta, the key vessels of blood transport supported by the LVAD pump. Surgeons at UCH, which was a site for the HeartMate 3 clinical trial, got plenty of practice performing these sternotomies.

For Ott’s procedure, however, UCH cardiothoracic surgeons Jay Pal, MD, PhD; Joseph Cleveland, MD; and Brett Reece, MD, performed a thoracotomy. They made much smaller incisions in the lower right and lower left portions of his chest – roughly two-and-a-half and four inches, respectively – to implant the pump, leaving Ott’s sternum intact. It marked the first time that a patient in the United States received a HeartMate 3 with the minimally invasive procedure.

From a clinical standpoint, the biggest advantage of the approach is that it preserves Ott’s sternum for what he hopes will be his next major procedure: a heart transplant, which will require a sternotomy.

“There are fewer adhesions for the transplant surgeon because the sternum is never impacted,” said Pal, who joined the University of Colorado School of Medicine early last summer as surgical director of the Mechanical Circulatory Support Program. The smaller incisions should also make it easier for patients like Ott to proceed from surgery to cardiac rehab and resume more of their normal day-to-day activities, Pal said.

Pressure for a pump

Two weeks after the procedure, Ott sat with his wife of 25 years, Janet, in a sun-splashed room in the Cardiothoracic Intensive Care Unit at UCH. He was still recovering from the implant as well as a second surgery to remove fluid from his left lung. He spoke softly, with some effort, smiling slightly when a visitor mentioned his groundbreaking procedure. How he got his LVAD wasn’t the most important thing to him. What mattered most was that he got it. He wants to be around for Janet; their daughters Ashley, 27, and Courtney, 23; and two granddaughters, ages three and six.

“I knew if I didn’t do it, I wouldn’t live to see my family,” Ott said. “It was time to get it done.”

Ott, who until recently made his living as a truck driver, said he was first diagnosed with congestive heart failure in 2006. His community providers tried to manage it with medications, but as his heart weakened, fluids collected, sometimes causing him to gain as much as 50 pounds in a week. He’d land in the hospital for three or four days at a time, hooked up to IV diuretics to drain the fluids and relieve the strain on his heart.

“He’d start losing the water, then he’d be sent home and we’d follow up with our physicians,” Janet said.

Ott kept driving as long as he could, but his heart failure put him on a revolving door of hospitalizations, including several in the past year. His heart sent him an increasingly powerful message this summer.

“I was very tired, very weak,” he said. He had trouble climbing the ladder on his truck and keeping his balance. In July, his primary care physician told him it wasn’t safe to keep working. He had to quit his job. He applied for disability. Janet’s job as a paraprofessional for a Denver high school became their sole source of income.

No time to spare

In mid-September, Ott’s cardiologist referred him to UCH, where he saw Natasha Altman, MD, an advanced heart failure specialist and transplant cardiologist who was to play a key role in halting his downward spiral. Altman had Ott hospitalized to reduce the fluid levels taxing his heart, but she didn’t stop there. She also initiated a thorough work-up, including labs and imaging, to see if he was a candidate for an LVAD. A whirlwind sequence followed

On Sept. 28, Altman called to tell Shaun he was approved for the HeartMate 3. She had seen Shaun none too soon. At that point, his heart was functioning at about one-third of its normal capacity, Altman explained. It was deteriorating rapidly an urgently needed pumping help.

Altman explained the conventional and minimally invasive approaches to the LVAD procedure – a choice that Pal would make – but before the surgery could take place, Shaun needed to clear another hurdle. His teeth presented an infection risk, so the UCH team arranged for a consult and X-rays at the nearby CU School of Dental Medicine on Sept. 29. Following that appointment, Shaun and Janet went home to pack a bag and returned to UCH, where he was hospitalized again. On Monday, Oct. 2, providers from the dental school came to the hospital to extract the teeth. Pal and his team implanted the HeartMate 3 the next day.

Shaun still faces recovery time in the ICU and later in the Cardiac step-down unit at UCH. He’ll need round-the-clock care for at least three months from Janet, Ashley and Courtney after he returns home. All of them are now learning from nurses and the Mechanical Circulatory Support Program team about changing the dressing at the pump port to prevent infection and maintaining the drive line that connects the pump inside the body to an external power source, among other tasks.

“We have a test we have to pass before we can take him home,” Janet said. “We’ve got other family and friends who will help us with details once we get there, but it will mostly be us girls taking care of him.”

Adding new skills

The Oct. 3 procedure was also a learning experience for providers. Pal got familiar with using thoracotomies to implant LVADs other than the HeartMate 3 during his time at the University of Washington. That experienced helped in working out the details of Ott’s procedure with Cleveland and Reece. The approach is less invasive than a sternotomy, but it requires more time, Pal said, mainly because surgeons have less anatomical real estate to work with.

“Any time you are making smaller incisions, you have less space, and that creates more of a challenge,” Pal said.

Cleveland, who was principal investigator for the HeartMate 3 trial at UCH, had performed one thoracotomy to implant an LVAD (though not a HeartMate 3), but the experience was a first for Reece. He noted that the heart failure cardiology team had become “very proficient” with the “more straightforward” sternotomy LVAD implants under the leadership of Cleveland, who served for many years as surgical director of the Mechanical Circulatory Support Program before Pal’s arrival.

“The new approach is more challenging on several levels,” Reece wrote in an email. “The exposure of both the heart and the aorta can be challenging based on patient anatomy. Having Jay’s comfort and patience with this made it feasible.”

Reece added that he saw firsthand the benefits of a thoracotomy when he performed a heart transplant on a patient implanted with an LVAD with the minimally invasive procedure, thus sparing a second sternotomy.

“The redo sternotomy can be incredibly difficult due to scar tissue and the relatively short time between the procedures,” Reece noted. “I was skeptical that this would be any different, but the reentry for the transplant was very straightforward.”

It’s especially important to develop expertise in using thoracotomies to implant LVADs because about half of all patients who get heart transplants at UCH have received bridge LVADs, Reece said. He believes the new approach is a big benefit for surgeons and for patients.

“After participating in both sides, I would take the increased complexity of the thoracotomy VAD for the ease of the transplant any day,” Reece said.

Questions asked and answered

For their part, the Otts said they are grateful to all the providers at UCH. “The team has been awesome,” Janet said.

They met Pal the day of the surgery. It was a tense time, obviously, but Pal eased their anxiety. “Dr. Pal explained everything – and I ask a lot of questions,” said Janet, the daughter of a nurse.

In fact, she said, that openness has been the hallmark of the care they’ve received throughout their time at UCH. The initial visit with Altman and her team, for example, lasted three hours.

“No one ever spent that long with us,” Janet said. The attention hasn’t lessened during the ICU stay, she added. “If I don’t understand something and need an explanation, they always break it down for me.”

Shaun Ott’s procedure is the first of many that will be needed to establish whether thoracotomies to implant HeartMate 3s and other LVADs can reliably minimize bleeding, shorten hospital stays, lessen post-operative pain and improve other key measures of quality care. But Jay Pal said the goals for Shaun Ott are what matter the most now.

“He came to us very ill,” Pal said. “We hope to ultimately get him back to a healthy state and back to a good level of comfort in what he does.”