Left Ventricular Reverse Remodeling With a Continuous Flow Left Ventricular Assist Device Measured by Left Ventricular End-Diastolic Dimensions and Severity of Mitral Regurgitation

Abstract

Pulsatile flow left ventricular assist devices (LVADs) maximally unload the left ventricle (LV), leading to reverse remodeling of the myopathic LV that manifests as decreased LV end-diastolic dimension (LVEDD) and decreased severity of mitral regurgitation (MR). There is a paucity of data, however, regarding the ability of continuous flow (CF) pumps to adequately decompress the LV to induce similar reverse remodeling. We sought to evaluate the effects of CF-LVADs on LV reverse remodeling. From March 2006 through July 2011, one hundred patients with chronic heart failure underwent implantation of CF-LVAD (93 HeartMate II LVADs and seven HeartWare LVADs) as bridge-to-transplant (n = 68) and destination therapies (n = 32). Echocardiograms and right heart catheterizations were reviewed preoperatively and at 1 and 6 months post-LVAD implantation. Mean age was 52.1 ± 12.1 years; etiology of heart failure was ischemic cardiomyopathy in 34 patients and nonischemic dilated cardiomyopathy in 66 patients. Median LVAD support time was 378.3 days; 371.5 days for patients who received bridge-to-transplant therapy and 422.2 days for patients who underwent destination therapy. Left ventricular end-diastolic dimension significantly decreased at 1 month post-LVAD implantation from 71.6 ± 12.4 to 58.3 ± 13.8 mm (p < 0.001). Severity of MR also significantly decreased from 76.0% of patients having moderate or severe MR preoperatively to 8.0% with moderate or severe MR at 1 month post-LVAD (p < 0.001). These reductions were maintained at 6 months. These data demonstrate the ability of a CF-LVAD to significantly decompress the LV, leading to significant reductions in LVEDD and severity of MR. This reverse remodeling was apparent in the early postoperative period and was sustained at 6 months. Further studies are warranted to investigate whether this correlates with clinical LV recovery.

Myocardial reverse remodeling: how far can we rewind?

“…In HFrEF, LVADs used as a "bridge to recovery" (129) have been shown to be capable of improving heart-rate reserve (125) systolic and diastolic function (95,176), with no evidence of subsequent regression (54). The improvement of molecular mechanisms such as improvement of ␤-adrenergic density on ventricular cardiomyocytes (125), enhancement of developed tension and calcium cycling upon catecholamine stimulation (47), upregulation of sarco(endo)plasmic reticulum Ca 2ϩ -ATPase (SERCA) (9,96), or recovery of T-tubule structure and function (105) underlies LAVDs benefits for contractile function.…”

Clinical implications of hemodynamic assessment during left ventricular assist device therapy

“…Continuous LV unloading leads to reverse remodeling with a decrease in LV dimension and increase in LV ejection fraction after several months following LVAD implantation, although the degree of change varies among patients [33,34]. Increase in peripheral circulation improves end-organ dysfunction [6], which can further improve patient hemodynamics.…”

Impact of Concomitant Mitral Valve Surgery With LVAD Placement: Systematic Review and Meta‐Analysis

“…Mitral valve regurgitation (MR) in patients undergoing CF‐LVAD implantation is common and is often secondary to functional enlargement of the mitral annulus due to left ventricular dilatation . As such, given that MR is often functional, ithas been hypothesized that it will be alleviated with left ventricular unloading following CF‐LVAD implantation via a combination of mechanisms involving a decrease in left ventricular dimension, mitral valve tenting area and a resultant reduction in mitral valve annular diameter .…”

“…There has been a recent growth in clinical interest to consider correction of all significant valvular pathology at the time of CF‐LVAD implantation . Yet, the indications and outcomes of concomitant mitral valvular intervention with CF‐LVAD implantation remain unknown.…”