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.

Keywords: heart failure; left ventricular assist device (LVAD); ventricular reconditioning; ventricular recovery; ventricular unloading.

Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Kaplan-Meier survival curve for the explant cohort. Overall survival was defined as days free from death, transplant, or device reimplantation.

Figure 2

Presence of mitral regurgitation before left ventricular assist device (VAD) implant and explant (p = 0.0001).