Left Ventricular Assist Device Decommissioning, the Journey so Far - Single Centre Experience

Abstract

Purpose Durable left ventricular assist device (LVAD) therapy is indicated in the treatment of advanced heart failure. Prolonged mechanical support may lead to reverse remodeling and recovery of LV function to such an extent that continued support is no longer necessary. When LV recovery occurs, the implanting center must exclude the LVAD from the circulation. Options include full surgical explant or isolation of the LVAD from the circulation without explant: ‘decommissioning’. Here we present a single-center experience of LVAD explant and decommissioning Methods We reviewed the local LVAD database (2006-2020). LVAD indication, time on support, survival, time to explant/decommission,date and indication for explant/decommission were recorded. Results 304 durable LVADs were implanted over the time reviewed. 22 patients, of which 18 male and 4 Female, underwent decommissioning/explanation of their device after a mean of 652 days . Indications for LVAD in this group were: 11 dilated cardiomyopathy, 2 familial cardiomyopathy, 7 myocarditis. In 10 patients LVAD therapy was discontinued following full myocardial recovery determined by echocardiography and right heart catheterization. In 11, partial myocardial recovery had occurred with explant/decommission expedited due to device complications. 1 experienced sudden pump failure with subsequent decommission without prior assessment of recovery. 2 patients underwent full primary surgical explant with the remaining 20 undergoing either a minimally invasive ligation of the outflow graft (n=9) or trans arterial vascular plug device occlusion (n=8). In patients undergoing less invasive procedures the driveline was cut and buried at the skin. 8 patients died following decommission/explant . 7 had partial recovery as assessed prior to intervention, with 1 patients with full recovery dying of non compliance to medical therapy. Conclusion Trans arterial vascular plug device occlusion of the LVAD outflow graft is a safe procedure in well selected patients with LV recovery, free from major procedural complications. LVAD infection is a major cause of re-intervention as following explant/decommission.