Long-Term Cardiac Remodeling after LVAD Deactivation for Myocardial Recovery

Abstract

Left ventricular assist devices (LVADs) through mechanical unloading can lead to reverse remodeling and in select individuals culminate in myocardial recovery permitting deactivation of LVAD support. Data on the sustainability of reverse remodeling as measured by myocardial structure (left ventricular internal diastolic diameter, LVIDD) and function (left ventricular ejection fraction, LVEF) after LVAD deactivation is poorly characterized in the literature. This is a single-center analysis from December 2011 to November 2018 of 14 patients who had LVAD deactivation in the setting of myocardial recovery. Patients were followed with serial echocardiography for up to 2 years post-LVAD deactivation. The mean age of patients was 41.8 ± 13.4 years, 42% were females, and all but one had a non-ischemic cardiomyopathy. Prior to LVAD deactivation, wedge pressure was 14 ± 6.7mmHg, cardiac index 2.8 ± 1.1L/m2, and peak VO2 19.5 ± 5.2mL/kg/min. Median LVAD support prior to deactivation was 18.0 months (range 3.3 to 104.4). 10 patients (71%) had the LVAD left in-situ with the outflow graft ligated and driveline divided and 4 (29%) had a full LVAD explant. Mean LVEF was 54.7 ± 7.2% prior to deactivation and LVIDD was 4.6 ± 0.7 cm. At 24 months, average LVEF had fallen to 36% while average LVIDD had increased to 5.6 cm (Table). Two patients (14%) had recurrent heart failure within a year and required cardiac transplantation. The remaining 12 patients (86%) are NYHA functional Class I or II and are alive without a heart failure hospitalization or need for LVAD or transplant at 2 years. LVAD deactivation following evidence of myocardial recovery is associated with a change in LV structure and function. Importantly, despite these changes, 86% of patients remained NYHA I or II without need for hospitalization, VAD, or transplant due to worsening of their cardiomyopathy at 2 years. These data show the promise of LVAD induced myocardial remodeling and warrant further investigation in a multi-center cohort.