Ventricular reconditioning and pump explantation in patients supported by continuous-flow left ventricular assist devices

Abstract

BACKGROUND The potential for myocardial reconditioning and device explantation after long-term continuous-flow left ventricular assist device (LVAD) support presents an opportunity to delay or avoid transplantation in select patients. METHODS Thirty of 657 patients with end-stage heart failure supported with continuous-flow LVADs were assessed for device explantation. Each patient underwent an individualized process of weaning focused on principles of ventricular unloading, gradual reconditioning, and transition to medical therapy. RESULTS After varying reconditioning periods, 27 patients (16 men, 11 women; age, 39 ± 12 years) underwent LVAD explant, and 3 patients (2 men, 1 woman; age, 22 ± 6 years) were evaluated for explantation but could not be weaned. The duration of LVAD support was 533 ± 424 days (range, 42– 1,937 days) for the explant cohort and 1,097 ± 424 days (range, 643–1,483) for the non-explant cohort. The LV end-diastolic dimension, LV ejection fraction, systolic pulmonary artery pressure, cardiac output, and cardiac index in the explant cohort were significantly improved at explantation (all, p < 0.05). Two late deaths occurred after LVAD explantation despite satisfactory native cardiac function, and 1 patient required resumption of LVAD support 2.7 years after device removal. The remaining explant patients remain in New York Heart Association classes I to II with medical management alone (mean survival post-explant, 1,172 ± 948 days). The 3 candidates who could not be weaned ultimately underwent transplantation. CONCLUSIONS The potential for recovery of native LV function after long-term continuous-flow LVAD support should encourage a more aggressive approach to ventricular reconditioning with the goal of device explantation and a return to medical management, particularly in young patients with dilated cardiomyopathy.

Minimally Invasive LVAD Deactivation in a 65-Year-Old Man with Recurrent Pump Thrombosis and Left Ventricular Recovery

“…8,9 Less invasive means of LVAD removal have recently been described, involving subxiphoid incision, surgical ligation of the outflow graft, and superficial excision of the driveline, leaving the inert pump in place. 10 Less common, however, is the method that we describe, which involves LVAD deactivation without surgical manipulation of the LVAD pump or its inflow and outflow components. The inflow cannula, outflow graft, and pump are all left in situ and only the driveline is transected and internalized; an AmplAtzer Vascular Plug is percutaneously deployed in the outflow graft to prevent excessive LV loading due to retrograde aortic flow.…”

Effective Illustration of Decommissioning of Left Ventricular Assist Device after Bridge-to-Recovery by Hybrid Minimally-Invasive Tactic: Anesthesia Substances

“…Furthermore, a full sternotomy and cardiopulmonary bypass can produce major bleeding, necessitating more blood and blood products, which may possibly affect the pulmonary vascular resistance and negatively impact the right ventricular function. With newer generation devices and advances in minimally invasive techniques for LVAD explantation, such that relatively virgin territory is used, cardiopulmonary bypass may be avoided [9][10][11], and the attendant risks are minimized.…”

“…Secondly, the pericardium remains mainly closed, controlling to further stabilize the right ventricular function, including avoidance of right ventricular dilatation. In addition, retained LVAD graft material has also been shown to be well tolerated [11]. Still, this technique is limited by poor visual control of cardiac pump function.…”

Personal and system requirements of a successful researching career in the field of multidisciplinary biomedical sciences: Personal review / overview

“…However, in the past several years, LVAD has been approved by the FDA to be used as a destination therapy ('bridge-to-destination'), which implies the fact that a patient with the implanted LVAD may be removed from a transplantation list since LVAD enables the patient to improve the quality of life and functional capacity ( ). The cardiac function improvement can be achieved to the extent that it is possible to remove LVAD and avoid heart transplantation with a very good long-term outcome (Birks, 2010;Frazier et al, 2015). The recovery rate sufficient to remove LVAD has been observed in only 5-24% of patients (Birks, 2010).…”

“…Међутим последњих неколико година LVAD је одобрен од стране FDA да се користи као дестинациона терапија ('bridge--tо-destination') што подразумева чињеницу да па-цијент са уграђеним (имплантираним) LVAD-ом може бити померен са листе за трансплантацију јер му LVAD омогућава побољшање квалитета . Побољшање функције срца може бити по-стигнуто до те мере да је могуће извадити LVAD и избећи трансплантацију срца са веома добрим дугорочним исходом (Birks, 2010;Frazier et al, 2015). Степен опоравка довољног да би се LVAD извадио је примећен код свега 5-24% пацијената Birks, 2010).…”