Left Ventricular Remodeling and Myocardial Recovery on Mechanical Circulatory Support

doi:10.1016/j.cardfail.2009.10.018

Journal of Cardiac Failure

Volume 16, Issue 2, February 2010, Pages 99-105

https://doi.org/10.1016/j.cardfail.2009.10.018 Get rights and content

Abstract

Background

Myocardial recovery after ventricular assist devices (VAD) is rare but appears more common in nonischemic cardiomyopathies (NICM). We sought to evaluate left ventricular (LV) end diastolic diameter (LVEDD) for predicting recovery after VAD.

Methods and Results

NICM patients receiving long-term mechanical support between 1996 and 2008 were reviewed. Subjects were divided into 3 groups: mild, moderate, and severe dilation (Group A: LVEDD <6.0 cm [n = 22]; Group B: 6.0-7.0 cm [n = 32]; Group C: >7.0 cm [n = 48], respectively). Overall, recovery (successful explant without transplantation) occurred in 14 of 102 subjects (14%). Of these, 2 died and 2 required transplantation within 1 year. Recovery was more common in patients without LV dilation (Groups A/B/C = 32%/22%/0%, P < .001), as was sustained recovery (alive and transplant free 1 year after explant; A/B/C = 27%/10%/0%, P = .001). Of the recovery patients in Group A, 6/7 (86%) had sustained recovery versus 3/6 (50%) in Group B.

Conclusions

Recovery occurred in 32% of NICM patients without significant LV dilation at time of VAD, the majority of whom experienced significant sustained recovery. Recovery was not evident in those with severe LV dilation. Routine echocardiography at the time of implant may assist in targeting patients for recovery after VAD.

Section snippets

Study Design and Data Collection

Data from the University of Pittsburgh Medical Center Cardiothoracic Transplantation Program's Transplant Patient Management System was reviewed retrospectively. The Transplant Patient Management System is a password-protected, HIPAA-compliant, web-based prospective data collection for all patients who receive mechanical circulatory support and is approved by the University of Pittsburgh Institutional Review Board. Patients were included in the present study if they had a NICM and were

Results

Between 1996 and 2008, 348 patients underwent VAD implantation at the University of Pittsburgh for planned long-term support. Of these, 241 were excluded, largely because of an etiology of ischemic cardiomyopathy (Fig. 1). Of the remaining 107 VAD implants, 102 had LVEDD measured before implantation and were included in this analysis. There were 22 patients in Group A (LVEDD <6.0 cm), 32 patients in Group B (LVEDD 6.0 to 7.0 cm), and 48 patients in Group C (LVEDD >7.0 cm). Baseline

Discussion

Although myocardial recovery may remain an uncommon event among VAD-supported patients, this study demonstrated that for subjects with NICM and minimal remodeling, device explant for recovery occurred in 32%. For the majority of these subjects recovery was maintained with an event-free survival at 1 year of 86%. Recovery was also experienced in 22% of subjects with moderate LV dilatation, although the 1-year transplant-free survival in this cohort was only 50%. These findings suggest preimplant

Acknowledgments

The authors would like to thank Karen Janosko, MSN and Manuela Reali, MD for assistance with data collection; Don Severyn, MS, Steve Winowich, BSChE, Rick Schaub, PhD, for clinical bioengineering support; Kathleen Lockard, RN, Stephanie Weaver, RN, and Lori DeGore, RN, Eileen Stanford, RN, for clinical management; Michelle D. Navoney, BS, Darrick Mowrey, BA, and Julianne Buchanan, MS for Transplant Patient Management System data management.

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Left ventricular assist devices are known for the treatment of heart failure. We present a patient who underwent emergent decommissioning of his left ventricular assist device after experiencing life-threatening hemorrhage. In this case, the patient's outflow graft was avulsed from his left subclavian artery. We used a covered stent to first exclude the outflow graft and an Amplatzer II plug (Abbott Cardiovascular) to then occlude the inflow cannula. Accessing the inflow cannula of the left ventricular assist device was challenging. In hindsight, we could have accessed and occluded the outflow graft via the left subclavian artery before deploying the covered stent.
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Citation Excerpt :
This applies particularly when the stability of TTE measurements during and between the LVAD interruption trials (performed over the next 2 to 4 weeks after maximum LV improvement) is also considered (Table 2).21,24,26 A clinical profile that should encourage the consideration of elective LVAD explantation is that of shorter duration of HF, nonischemic etiology, younger patient age, and cardiac improvement within the first 6 months of LVAD support.4,5,16,21,22,46 In patients with normal RHC-derived off-pump hemodynamics before explantation, off-pump LVEF ≥ 45% at rest showed a predictive value of 74% for ≥ 5-years postexplant cardiac stability.24
In carefully selected patients with ventricular assist devices (VADs), good long-term results after device weaning and explantation can be achieved when reverse remodelling and improvement of native cardiac function occur. Monitoring of cardiac size, geometry, and function after initial VAD implantation is necessary to identify such patients. Formal guidelines for recovery assessment in patients with VADs do not exist, and protocols for recovery assessment and criteria for device weaning and explantation vary among centres. Barriers to evaluation of cardiac recovery include technical problems in obtaining echo images in patients with VADs, time restrictions for necessary VAD reductions/interruptions during assessment, and regurgitant flow patterns that occur with interruption of continuous flow VADs. The few larger studies addressing cardiac recovery after VAD implantation employed varied study designs, limiting interpretation. Current clinical practice is guided largely by local practice patterns, case reports, and small case series, and the available body of research—consisting mostly of expert opinions—has not been systematically addressed. This summary reviews evidence and expert opinion on VAD-promoted cardiac recovery assessment, its reliability, and associated challenges.
Chez les patients soigneusement sélectionnés, porteurs d’un dispositif d’assistance ventriculaire (DAV), on peut s’attendre à obtenir de bons résultats à long terme après le sevrage et l’explantation lorsque surviennent le remodelage inverse et l’amélioration de la fonction cardiaque native. Le monitorage de la taille, de la géométrie et de la fonction cardiaque après l’implantation initiale du DAV est nécessaire pour identifier ces patients. Il n’existe pas de lignes directrices formelles sur l’évaluation du rétablissement des patients porteurs d’un DAV, mais on observe que les protocoles d’évaluation et les critères du rétablissement pour le sevrage et l’explantation du dispositif varient selon les centres. Parmi les obstacles à l’évaluation du rétablissement cardiaque, on retrouve les problèmes techniques dans l’obtention des images échocardiographiques chez les patients porteurs d’un DAV, les restrictions de temps pour les réductions/interruptions nécessaires du DAV durant l’évaluation, et les profils du débit de régurgitation qui surviennent lors de l’interruption des DAV à débit continu. Quelques études plus vastes qui portent sur le rétablissement cardiaque après l’implantation d’un DAV n’ont pas de plan d’étude comparable. La pratique clinique actuelle est en grande partie orientée par les schémas de pratique locale, les observations et les petites séries de cas, mais le corpus de recherche disponible, qui est principalement composé de l’opinion d’experts, n’a pas été abordé de manière systématique. Ce résumé passe en revue les données probantes et l’opinion d’experts sur l’évaluation du rétablissement cardiaque favorisé par le DAV, sa fiabilité et les enjeux qui y sont associés.
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Citation Excerpt :
Left ventricular unloading by mechanical support has the potential to disrupt the vicious cycle of volume and pressure overload leading to cardiac remodeling. Several studies have shown reverse remodeling in LVAD-supported patients, in some sufficient to allow for explantation of the device (17,18,22,35–40). These observations have opened the gateway to the field of LVAD-induced cardiac recovery.
The number of centers with left ventricular assist device (LVAD) research programs focused on cardiac recovery is very small. Therefore, this phenomenon has been reported in real-world multi-center registries as a rare event.
This study evaluated the incidence of cardiac recovery with an a priori LVAD implantation strategy of bridge-to-recovery (BTR) and constructed a recovery predictive model.
The study included LVAD recipients registered in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Cardiac recovery was evaluated in BTR and non-BTR patients. A weighted score was derived and externally validated in patients of the Utah Cardiac Recovery (UCAR) program.
Of 15,138 INTERMACS patients, cardiac recovery occurred in 192 (1.3%). The incidence of recovery was 11.2% (n = 14) in BTR compared with 1.2% (n = 178) in non-BTR patients (p < 0.0001). Independent predictors of recovery included: age <50 years, non-ischemic cardiomyopathy, time from cardiac diagnosis <2 years, absence of ICD, creatinine ≤1.2 mg/dl, and LVEDD <6.5 cm (c-index: 0.85; p < 0.0001). A weighted score termed I-CARS, effectively stratified patients based on their probability of recovery. I-CARS was validated in the UCAR cohort (n = 190) with good performance (AUC: 0.94; 95% CI: 0.91 to 0.98). One-year survival after LVAD explantation, available in INTERMACS for 21 (11%) patients, was 86%.
The incidence of cardiac recovery is higher in patients implanted with an a priori BTR strategy. We developed a simple tool to help identify patients in whom recovery is feasible. In BTR patients with favorable characteristics, I-CARS suggests a 24% probability of successful LVAD explantation. Large-scale studies to better address post-explantation outcomes are warranted.

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: Dr. Simon is supported by the NIH Roadmap Multidisciplinary Clinical Research Career Development Award (KL2 RR024154). Dr. McNamara is supported by NIH AwardR01 HL75038, and K24 HL069912. Dr. Primack is supported by a grant from the National Cancer Institute (K07-CA114315) and a grant from the Maurice Falk Foundation. Dr. Gorcsan is supported in part by NIH award K24 HL04503 and R01 HL086918. Dr. Kormos is on the medical advisory boards of Thoratec Corporation & World Heart Corporation. No other authors report relationships with industry.

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Clinical InvestigationLeft Ventricular Remodeling and Myocardial Recovery on Mechanical Circulatory Support

Abstract

Background

Methods and Results

Conclusions

Section snippets

Study Design and Data Collection

Results

Discussion

Acknowledgments

J Thorac Cardiovasc Surg

J Heart Lung Transplant

J Heart Lung Transplant

J Heart Lung Transplant

J Heart Lung Transplant

J Heart Lung Transplant

Ann Thorac Surg

J Heart Lung Transplant

J Am Coll Cardiol

J Heart Lung Transplant

Ann Thorac Surg

J Heart Lung Transplant

J Am Coll Cardiol

J Heart Lung Transplant

Ann Thorac Surg

J Heart Lung Transplant

Long-term use of a left ventricular assist device for end-stage heart failure

N Engl J Med

Clinical Investigation
Left Ventricular Remodeling and Myocardial Recovery on Mechanical Circulatory Support