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

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    14 Citations (Scopus)
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    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 languageEnglish
    Pages (from-to)1560-1570
    Number of pages11
    JournalThe Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
    Volume40
    Issue number12
    Early online date11 Aug 2021
    DOIs
    Publication statusPublished - 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

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