LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events

Eleanor F Gerhard; Lu Wang; Ramesh Singh; Stephan Schueler; Leonard D Genovese; Andrew Woods; Daniel Tang; Nicola Robinson Smith; Mitchell A Psotka; Sian Tovey; Shashank S Desai; Djordje G Jakovljevic; Guy A MacGowan; Palak Shah

doi:10.1016/j.healun.2021.08.001

LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events

Eleanor F Gerhard, Lu Wang, Ramesh Singh, Stephan Schueler, Leonard D Genovese, Andrew Woods, Daniel Tang, Nicola Robinson Smith, Mitchell A Psotka, Sian Tovey, Shashank S Desai, Djordje G Jakovljevic, Guy A MacGowan, Palak Shah

Research output: Contribution to journal › Article › peer-review

11 Citations (Scopus)

63 Downloads (Pure)

Abstract

BACKGROUND: Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown.

METHODS: This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant.

RESULTS: During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years.

CONCLUSIONS: LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.

Original language	English
Pages (from-to)	1560-1570
Number of pages	11
Journal	The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
Volume	40
Issue number	12
Early online date	11 Aug 2021
DOIs	https://doi.org/10.1016/j.healun.2021.08.001
Publication status	Published - Dec 2021

Bibliographical note

Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Licensed under the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International http://creativecommons.org/licenses/by-nc-nd/4.0/

Copyright © and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders.

Funder

Funding Information: The work in this study is supported by a National Institutes of Health, Career Development Award K23 1K23HL143179 awarded to Dr. Shah Funding Information: Dr. Shah reports support for this work from an NIH K23 Career Development Award 1K23HL143179 and grant support from American Heart Association and/or Enduring Hearts, Abbott, Merck, Roche and Bayer and personal fees from Procyrion, Roche, Novartis, and Ortho Clinical Diagnostics for unrelated work. Dr. Wang is supported by the National Institute for Health Research (NIHR) Blood and Transplant Research Unit (BTRU) in Organ Donation and Transplantation at the University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant (NHSBT). Dr. Psotka has received personal fees from Amgen, Cytokinetics, and Windtree, and grant support from the United States Food and Drug Administration. Dr. Desai receives honoraria for speaking from Abbott. Drs MacGowan and Jakovljevic are supported by European Union's Horizon 2020 Research and Innovation Programme under Grant Agreement no. 777204 and the UK National Institute of Health Research.

Keywords

LVAD, myocardial recovery
heart failure
mechanical circulatory support
mechanical unloading
reverse cardiac remodeling

ASJC Scopus subject areas

Surgery
Pulmonary and Respiratory Medicine
Cardiology and Cardiovascular Medicine
Transplantation

Access to Document

10.1016/j.healun.2021.08.001

Post-PrintAccepted author manuscript, 487 KBLicence: CC BY-NC-ND

Cite this

Gerhard, E. F., Wang, L., Singh, R., Schueler, S., Genovese, L. D., Woods, A., Tang, D., Smith, N. R., Psotka, M. A., Tovey, S., Desai, S. S., Jakovljevic, D. G., MacGowan, G. A., & Shah, P. (2021). LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 40(12), 1560-1570. Advance online publication. https://doi.org/10.1016/j.healun.2021.08.001

LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events. / Gerhard, Eleanor F; Wang, Lu; Singh, Ramesh et al.
In: The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, Vol. 40, No. 12, 12.2021, p. 1560-1570.

Research output: Contribution to journal › Article › peer-review

Gerhard, EF, Wang, L, Singh, R, Schueler, S, Genovese, LD, Woods, A, Tang, D, Smith, NR, Psotka, MA, Tovey, S, Desai, SS, Jakovljevic, DG, MacGowan, GA & Shah, P 2021, 'LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events', The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, vol. 40, no. 12, pp. 1560-1570. https://doi.org/10.1016/j.healun.2021.08.001

Gerhard EF, Wang L, Singh R, Schueler S, Genovese LD, Woods A et al. LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2021 Dec;40(12):1560-1570. Epub 2021 Aug 11. doi: 10.1016/j.healun.2021.08.001

@article{e3ac927b830b4a4b94fe21d88c71739f,

title = "LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events",

abstract = "BACKGROUND: Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown.METHODS: This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant.RESULTS: During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years.CONCLUSIONS: LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.",

keywords = "LVAD, myocardial recovery, heart failure, mechanical circulatory support, mechanical unloading, reverse cardiac remodeling",

author = "Gerhard, {Eleanor F} and Lu Wang and Ramesh Singh and Stephan Schueler and Genovese, {Leonard D} and Andrew Woods and Daniel Tang and Smith, {Nicola Robinson} and Psotka, {Mitchell A} and Sian Tovey and Desai, {Shashank S} and Jakovljevic, {Djordje G} and MacGowan, {Guy A} and Palak Shah",

note = "Copyright {\textcopyright} 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved. Licensed under the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International http://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright {\textcopyright} and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. ",

year = "2021",

month = dec,

doi = "10.1016/j.healun.2021.08.001",

language = "English",

volume = "40",

pages = "1560--1570",

journal = "The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation",

issn = "1053-2498",

publisher = "Elsevier USA",

number = "12",

}

TY - JOUR

T1 - LVAD decommissioning for myocardial recovery

T2 - Long-term ventricular remodeling and adverse events

AU - Gerhard, Eleanor F

AU - Wang, Lu

AU - Singh, Ramesh

AU - Schueler, Stephan

AU - Genovese, Leonard D

AU - Woods, Andrew

AU - Tang, Daniel

AU - Smith, Nicola Robinson

AU - Psotka, Mitchell A

AU - Tovey, Sian

AU - Desai, Shashank S

AU - Jakovljevic, Djordje G

AU - MacGowan, Guy A

AU - Shah, Palak

N1 - Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved. Licensed under the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International http://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright © and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders.

PY - 2021/12

Y1 - 2021/12

N2 - BACKGROUND: Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown.METHODS: This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant.RESULTS: During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years.CONCLUSIONS: LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.

AB - BACKGROUND: Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown.METHODS: This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant.RESULTS: During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years.CONCLUSIONS: LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.

KW - LVAD, myocardial recovery

KW - heart failure

KW - mechanical circulatory support

KW - mechanical unloading

KW - reverse cardiac remodeling

UR - http://www.scopus.com/inward/record.url?scp=85114098386&partnerID=8YFLogxK

U2 - 10.1016/j.healun.2021.08.001

DO - 10.1016/j.healun.2021.08.001

M3 - Article

C2 - 34479776

SN - 1053-2498

VL - 40

SP - 1560

EP - 1570

JO - The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation

JF - The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation

IS - 12

ER -

LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events

Abstract

Bibliographical note

Funder

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Cite this