Ventricular Unloading In Patients Research Articles

Unloading in cardiogenic shock: the rationale and current evidence.

Discussing the rationale and current evidence for left ventricular unloading in cardiogenic shock. Microaxial flow pumps (MFP) and intra-aortic balloon pumps (IABP) augment cardiac output while simultaneously unloading the left ventricle (e.g. reducing left ventricular pressure), thereby targeting a key mechanism of cardiogenic shock. A recent randomized trial has shown a mortality reduction with MFP in selected patients with cardiogenic shock, strengthening the rationale for this strategy, although the evidence for the IABP is so far neutral. MFP/IABP can also be used concomitantly with veno-arterial extracorporeal membrane oxygenation (va-ECMO) to alleviate the va-ECMO-related increase in left ventricular afterload, to facilitate weaning and ultimately to improve myocardial recovery and prognosis of affected patients. However, the use of MFP/IABP in this indication solely relies on retrospective data, which need to be interpreted with caution, especially as these strategies are associated with more complications. Currently ongoing randomized trials will help to further clarify the role of left ventricular unloading in patients on va-ECMO. Left ventricular unloading addresses a key mechanism of cardiogenic shock, with strong evidence to support MFP use in selected patients, but further randomized controlled trials are required to clarify the role of different devices/strategies for the overall shock population.

Left ventricular unloading in patients supported with veno-arterial extra corporeal membrane oxygenation; an international EuroELSO survey.

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) improves end-organ perfusion in cardiogenic shock but may increase afterload, which can limit cardiac recovery. Left ventricular (LV) unloading strategies may aid cardiac recovery and prevent complications of increased afterload. However, there is no consensus on when and which unloading strategy should be used. An online survey was distributed worldwide via the EuroELSO newsletter mailing list to describe contemporary international practice and evaluate heterogeneity in strategies for LV unloading. Of 192 respondents from 43 countries, 53% routinely use mechanical LV unloading, to promote ventricular recovery and/or to prevent complications. Of those that do not routinely unload, 65% cited risk of complications as the reason. The most common indications for unplanned unloading were reduced arterial line pulsatility (68%), pulmonary edema (64%) and LV dilatation (50%). An intra-aortic balloon pump was the most frequently used device for unloading followed by percutaneous left ventricular assist devices. Echocardiography was the most frequently used method to monitor the response to unloading. Significant variation exists with respect to international practice of ventricular unloading. Further research is required that compares the efficacy of different unloading strategies and a randomized comparison of routine mechanical unloading versus unplanned unloading.

Timing of active left ventricular unloading in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy

Abstract Aim To evaluate the impact of timing of active left ventricular (LV) unloading in relation to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation on outcomes of patients with cardiogenic shock (CS). Methods and results Data from 421 patients with CS treated with active LV unloading on top of VA-ECMO at 18 tertiary-care centers in 4 countries were collected. Only patients in whom both devices were implanted within 24 hours of each other were considered and patients were stratified by timing of device implantation in early vs. delayed active LV unloading (e.g. active LV unloading before vs. after VA-ECMO). Cox and logistic regression models (adjusted for age, sex, lactate, cardiopulmonary resuscitation (CPR), VA-ECMO assisted CPR and enrollment center) were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as several safety outcomes. Overall, 310 (73.6%) patients were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (hazard ratio 0.63, 95% confidence interval 0.46–0.87) and a higher likelihood of weaning from mechanical ventilation (odds ratio 1.25, 95% confidence interval 1.03–1.52), but not with more complications. Importantly, postponing active LV unloading in these patients was associated with higher mortality risk (Figure 1), and lower likelihood of successful weaning from mechanical ventilation. Conclusion This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO as a primary treatment strategy, as opposed to a bail-out approach. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Unrestricted research grant from Abiomed

Left ventricular unloading with Impella versus IABP in patients on VA-ECMO for cardiogenic shock

Abstract Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in shock is limited by increased left ventricular afterload. Impella and intra-aortic balloon pump (IABP) can be used in conjunction with VA-ECMO to help unload the left ventricle. Data comparing the two strategies are limited. Purpose We performed a systematic review and meta-analysis of published data to compare outcomes of patients with shock supported by VA-ECMO in conjunction with Impella versus IABP. Methods We conducted a search of Medline, Embase, and Cochrane databases to identify studies comparing the use of Impella versus IABP in patients on VA-ECMO. The primary outcome of interest was all-cause mortality (in-hospital or 30-day). Secondary outcomes included transition to destination therapy with left ventricular assist device (LVAD) or transplant, stroke, need for continuous renal replacement therapy (CRRT), bleeding, and hemolysis. Risk ratios (RR) with 95% confidence interval and the heterogeneity statistic I2 were reported for each outcome. Results Six observational studies with a total of 629 patients were included in the analysis. Of these, 205 (33%) and 424 (67%) patients were supported by Impella and IABP respectively, in addition to VA-ECMO. All six studies reported the primary outcome. No difference was observed in all-cause mortality between VA-ECMO with Impella and VA-ECMO with IABP (RR 1.02 [0.74–1.40], I2=74%). Similar rates were observed for transition to LVAD or transplant (RR 0.75 [0.45–1.27], I2=0%), stroke (RR 1.50 [0.80–2.83], I2=0%), and need for CRRT (RR 1.04 [0.82–1.32], I2=0%). However, use of VA-ECMO with Impella was associated with a higher risk of bleeding (RR 1.91 [1.28–2.86], I2=68%) and hemolysis (RR 4.61 [1.24–17.17], I2=66%) as compared with use of VA-ECMO with IABP. Conclusion In patients with shock requiring VA-ECMO, concurrent use of Impella and IABP had similar risk of mortality, transition to LVAD/transplant, stroke, and need for CRRT. However, Impella use was associated with higher risk of bleeding and hemolysis. Randomized trials are needed to identify the optimal strategy for left ventricular unloading in patients with cardiogenic shock on VA-ECMO. Funding Acknowledgement Type of funding sources: None.

The CorInnova Implantable Cardiac Assist System for Direct Cardiac Compression.

The CorInnova cardiac compression device (CorInnova, Inc., Houston, TX, USA) is designed to provide direct biventricular support, increase cardiac output, and improve ventricular unloading in patients with heart failure. Placed within the pericardium and surrounding both ventricles, the device has two concentric sets of thin-film polyurethane chambers: (1) inner (epicardial) saline-filled chambers that conform intimately to the epicardial surface, eradicating any gaps in the interface between the device and the heart; and (2) outer air-filled chambers cycled to provide epicardial compression during systole and negative epicardial pressure during diastole, consistent with physiological cardiac contraction and relaxation. A superelastic, collapsible Nitinol frame gives the device structure, enables minimally invasive self-deployment, and enhances diastolic filling. Preclinical testing has been extremely promising, with improvements in cardiac output and other cardiac parameters in animal heart failure models. This potentially transformative technology is moving rapidly toward first-in-human use. The CorInnova device may provide an effective device-based solution for patients with heart failure who currently have few or limited mechanical cardiac support options, including patients with biventricular cardiac failure, those with right heart failure, those who are older, and those who are of smaller size. It can be removed easily and requires minimal maintenance. An important, unique feature of this technology is that it provides mechanical cardiac assistance without blood contact or need for anticoagulation. The CorInnova device may be particularly important for those patients who have contraindications to anticoagulation due to allergy, neurological bleeds, or preexisting hemorrhage. No other mechanical circulatory support device addresses these underserved heart-failure populations.

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

Right Ventricular Failure and Left Ventricular Transmural Pressure as Predictors of Successful Left Ventricular Unloading in Patients with HM 3 CF-LVAD

<h3>Purpose</h3> To investigate whether right ventricular failure was associated with impaired left ventricular (LV) unloading during Left Ventricular Assist Device (LVAD) speed optimization. <h3>Methods</h3> Patients with Heartmate (HM) 3 LVADs implanted between January 2016 and April 2021 who had undergone speed optimization using right heart catheterization within one year from the implant were identified. We included patients with inadequate LV unloading as demonstrated by a pulmonary capillary wedge pressure (PCWP) above 12mmHg. We grouped patients based on the presence of right ventricular (RV) failure, defined as a right atrial pressure (RAP) to PCWP ratio >0.8. We also studied the impact of left ventricular transmural pressure (LVTMP) as a surrogate for true LV preload. Mean changes with increased pump speed (per 100 RPM) in PCWP were determined by the generalized linear mixed model. Line plots were used to present the slope of PCWP. All the analyses were performed on Stata version 17.0 (StataCorp LLC, College Station, TX, USA). A p-value of <0.05 was considered statistically significant. <h3>Results</h3> Thirty-six patients were included in this study. The median age was 52.5±11.8, 86.1% were male, 77.8% were implanted as destination therapy, and the median number of RPM changes was 3.5. Patients with RA/PCWP>0.8 had a trend towards lower decrease in PCWP with pump speed increase compared to RA/PCWP ≤0.8 (-0.57 vs -0.72, P=0.06, Figure 1A). Reduced LVTMP, defined as PCWP-RAP ≤4 mmHg, was significantly associated with a decreased slope of PCWP reduction with LVAD speed (-0.44 vs -0.96, p=0.02, Figure 1B). <h3>Conclusion</h3> In patients with RV failure the unloading of the LV is impaired, likely due to reduced LVTMP which is a surrogate for true LV preload. The presence of RV failure should be taken into account in the optimization of the LV pressures with speed optimization in HM3 patients.

Clinical findings associated with incomplete hemodynamic left ventricular unloading in patients with a left ventricular assist device

Introduction and objectivesThe effect of a centrifugal continuous-flow left ventricular assist device (cfLVAD) on hemodynamic left ventricular unloading (HLVU) and the clinical conditions that interfere with hemodynamic optimization are not well defined. MethodsWe retrospectively evaluated the likelihood of incomplete HLVU, defined as high pulmonary capillary wedge pressure (hPCWP)> 15mmHg in 104 ambulatory cfLVAD patients when the current standard recommendations for cfLVAD rotor speed setting were applied. We also evaluated the ability of clinical, hemodynamic and echocardiographic variables to predict hPCWP in ambulatory cfLVAD patients. ResultsTwenty-eight percent of the patients showed hPCWP. The variables associated with a higher risk of hPCWP were age, central venous pressure, absence of treatment with renin-angiotensin-aldosterone system inhibitors, and brain natriuretic peptide levels. Patients with optimal HLVU had a 15.2±14.7% decrease in postoperative indexed left ventricular end-diastolic diameter compared with 8.9±11.8% in the group with hPCWP (P=.041). Independent predictors of hPCWP included brain natriuretic peptide and age. Brain natriuretic peptide <300 pg/mL predicted freedom from hPCWP with a negative predictive value of 86% (P <.0001). ConclusionsAn optimal HLVU can be achieved in up to 72% of the ambulatory cfLVAD patients when the current standard recommendations for rotor speed setting are applied. Age, central venous pressure and therapy with renin-angiotensin-aldosteron system inhibitors had a substantial effect on achieving this goal. Brain natriuretic peptide levels and the magnitude of reverse left ventricular remodeling seem to be useful noninvasive tools to evaluate HLVU in patients with functioning cfLVAD.

Temporary mechanical circulatory support devices: updates from recent studies.

Over the past several years, the role of short-term mechanical circulatory support (MCS) devices has become the dominant focus in efforts to improve outcomes in patients with cardiogenic shock (CS). Alongside these efforts, temporary MCS devices have been increasingly used to support patients prior to cardiac surgery, during high-risk percutaneous coronary intervention, awaiting cardiac transplantation, and in the setting of refractory cardiac arrest. The present review aims to provide an update on the recent literature evaluating the evolving role of temporary MCS devices, and to provide insights into the current challenges and future directions of MCS research. Recent observational data have demonstrated potential roles for intra-aortic balloon pump preoperatively in high-risk patients awaiting coronary artery bypass grafting, and advanced heart failure patients awaiting transplantation. Impella continues to demonstrate promising results as part of an early MCS strategy in CS, as a temporary bridge to transplantation, and as a mechanism for left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation (ECMO). Finally, the first randomized trial of ECMO facilitated resuscitation in the United States demonstrated improved survival in patients with refractory out of hospital cardiac arrest. Though randomized data remains limited, observational data continue to support the role of temporary MCS devices in a variety of clinical settings.

Percutaneous Left Ventricular Assist Device Leads to Heart Rhythm Stabilisation in Cardiogenic Shock: Results from the Dresden Impella Registry

Severe heart rhythm disturbances (SHRDs) occur regularly in cardiogenic shock (CS). Percutaneous left ventricular assist devices (pLVADs) can actively unload the left ventricle (LV), decreasing left ventricular end-diastolic pressure and wall tension, which are suspected parameters for the induction and maintenance of arrhythmias. The aim of this study was to describe effects of LV unloading on SHRD. In the Dresden Impella Registry, 97 patients received an Impella CP in refractory CS. Of them, 19 had SHRDs, which were not stopped by common therapeutic strategies such as electrical defibrillation or antiarrhythmic drugs. They were only stopped after implantation of a micro-axial heart pump. This phenomenon was referred to as heart rhythm stabilisation (HRS). Clinical outcome and laboratory parameters were assessed and risk factors for the occurrence of HRS were identified. All 19 patients with refractory SHRD terminated immediately into a stable heart rhythm after insertion of the micro-axial heart pump. In 37% no additional defibrillation was needed. Of the patients with HRS, CS was mostly caused by myocardial infarction (68%). Resuscitation before pLVAD was performed in 89% for more than 30 minutes. Patients with HRS were resuscitated more frequently and for a longer duration than patients without HRS. After HRS, the serum lactate and norepinephrine dosage decreased in the first 12 hours, whereas left ventricular ejection fraction increased by 95%. Left ventricular unloading in patients with CS seems to be an option for treating patients with sustained life-threatening tachycardia, who are refractory to common treatment.

Intrinsic Myocardial Function and Relationship with Left Ventricular Unloading in Patients Supported on CF-LVAD Therapy

Despite strong interest in left ventricular recovery, no clinical data exist on the relationship between intrinsic myocardial function and reverse remodeling or LVAD unloading. We sought to evaluate this interaction. Patients implanted with continuous flow LVADs between 2015 and 2018 who underwent combined LHC/RHC ramp protocol at a single institution were enrolled. Exclusion criteria were significant valve disease, inability to optimize hemodynamically during ramp study, or inotropic therapy. Hemodynamic data including peak LV dP/dt and tau were obtained. Among a cohort of 62 patients undergoing LHC/RHC study, 25 patients were included (12 with LVEF ≥25%, augLV, and 13 with LVEF <25%, impLV). Important hemodynamic differences between augLV and impLV included aortic pulse width, tau, and peak LV dP/dt. On linear regression, aortic pulse width was associated with each of LV systolic pressure, peak LV dP/dt, and LVEF% (r = 0.58, 0.59, and 0.40 with p < 0.05 for all). Both adjusted tau and LV dP/dt were associated with PCWP values (r = 0.41, p < 0.0001 and r = -0.52, p <0.0001, respectively); however, an inverse relationship between LVAD speed and strength of association with PCWP was noted. Significant correlations between intrinsic myocardial function and reverse remodeling as well as aortic pulsatility were noted. A greater reliance on LVAD for unloading is noted at higher speeds, suggesting excessive LVAD unloading may be detrimental. Future work should focus on defining the optimal level of LVAD support, particularly in relation to LV recovery and functional outcomes.

Impact of Cardiac Resynchronization Therapy on Left Ventricular Unloading in Patients with Implanted Left Ventricular Assist Devices

Cardiac resynchronization therapy (CRT) and left ventricular assist devices (LVADs) are common heart failure therapies; however, little is known regarding the concomitant use of these devices. We aim to evaluate unloading differences in LVAD patients with and without active biventricular pacing. Left ventricular assist device patients with and without CRT prospectively underwent ramp hemodynamic/echocardiographic testing. Patients with >95% biventricular pacing comprised the active CRT pacing group; all others (no device, implantable cardioverter defibrillator only, CRT without biventricular pacing) were categorized into the non-CRT pacing group. Invasive hemodynamics and echocardiographic characteristics (left ventricular end-diastolic/systolic diameter and valvular regurgitation) were measured at baseline and at incremental speed changes. Unloading slopes were calculated using linear regression modeling for individual hemodynamics and echocardiographic characteristics across speeds. Among 62 LVAD patients (age 59.6 ± 11.4 years, 60% male), 25 had active CRT pacing. There was no significant difference in echocardiographic or hemodynamic characteristics at baseline or final set speeds between CRT groups. Similarly, no significant differences were noted in the unloading characteristics. In LVAD patients, active biventricular pacing is unlikely to improve echocardiographic or hemodynamic characteristics.

Impact of Heart Failure Etiology on Ventricular Unloading in Patients Supported with Left Ventricular Assist Devices (LVADs)

Impact of Heart Failure Etiology on Ventricular Unloading in Patients Supported with Left Ventricular Assist Devices (LVADs)

(313) - Echocardiography Accurately Tracks Left Ventricular Unloading in Patients Supported with a HeartMate II LVAD Undergoing Ramp Testing

(313) - Echocardiography Accurately Tracks Left Ventricular Unloading in Patients Supported with a HeartMate II LVAD Undergoing Ramp Testing

(210) - Outcome of the Impella Device for Mechanical Circulatory Support in Patients With Refractory Cardiogenic Shock

Acute cardiogenic shock is associated with high mortality rates and mechanical circulatory devices have been increasingly used in this setting. We report the outcome of the Impella device for acute circulatory support in cardiogenic shock from a large-volume single institution. We performed a retrospective study of patients who underwent placement of the Impella device from December 2010 to July 2014. We analyzed patient’s demographics, hemodynamics, echocardiographic and operative details, in-hospital, 6-month and 1-year survival. Sixty consecutive patients were included in our study. The mean age was 53.4±15.4 years, 47 patients (78.3%) were men. Main indications for placement of the Impella device were post-cardiotomy cardiogenic shock in 31 (51.7%) patients, acute myocardial infarction in 14 (23.3%), acute decompensation of chronic cardiomyopathy in 9 (15.0%), myocarditis in 2 (3.3%). Sixteen Impella devices were implanted for left ventricular unloading in patients supported by Extra-Corporeal Membrane Oxygenation (ECMO). Of the 60 patients, 55(91.7%) received the Impella 5.0 and 5 (8.3%) the Impella 2.5 and 1(1.7%) the Impella CP. The mean duration of Impella support was 10.7±7.4 days (range1-37). Weaning of the Impella device was possible because of left ventricular functional recovery in 28( 46.7%) patients, bridge to long term LVAD (Left Ventricular Assist Device) in 6 (10.0%), bridge to transplantation in 6 (10.0%). Thirteen (21.7%) patients died with the Impella device in place (associated with ECMO), 8 patients were switched to double central ECMO because of severe septic shock or right ventricular failure. In hospital, 6-month and 1-year survival rates were 56.7%, 55.0% and 53.3% respectively.Five patients presented with device related complications: device malfunction, device migration, high purge pressures, axillary hematoma and axillary infection. No patient experienced new onset of acute pulmonary oedema while being supported by the Impella device. To date this is the largest series of patients undergoing placement of the Impella device for acute cardiogenic shock. In-hospital and one-year mortality rates were acceptable in these critical patients. Two third of the patients were able to be weaned from the device or bridged to other therapies. Few device-related complications were reported.

Enhanced Ca2+ influx through cardiac L-type Ca2+ channels maintains the systolic Ca2+ transient in early cardiac atrophy induced by mechanical unloading

Cardiac atrophy as a consequence of mechanical unloading develops following exposure to microgravity or prolonged bed rest. It also plays a central role in the reverse remodelling induced by left ventricular unloading in patients with heart failure. Surprisingly, the intracellular Ca2+ transients which are pivotal to electromechanical coupling and to cardiac plasticity were repeatedly found to remain unaffected in early cardiac atrophy. To elucidate the mechanisms underlying the preservation of the Ca2+ transients, we investigated Ca2+ cycling in cardiomyocytes from mechanically unloaded (heterotopic abdominal heart transplantation) and control (orthotopic) hearts in syngeneic Lewis rats. Following 2 weeks of unloading, sarcoplasmic reticulum (SR) Ca2+ content was reduced by ~55 %. Atrophic cardiac myocytes also showed a much lower frequency of spontaneous diastolic Ca2+ sparks and a diminished systolic Ca2+ release, even though the expression of ryanodine receptors was increased by ~30 %. In contrast, current clamp recordings revealed prolonged action potentials in endocardial as well as epicardial myocytes which were associated with a two to fourfold higher sarcolemmal Ca2+ influx under action potential clamp. In addition, Cav1.2 subunits which form the pore of L-type Ca2+ channels (LTCC) were upregulated in atrophic myocardium. These data suggest that in early cardiac atrophy induced by mechanical unloading, an augmented sarcolemmal Ca2+ influx through LTCC fully compensates for a reduced systolic SR Ca2+ release to preserve the Ca2+ transient. This interplay involves an electrophysiological remodelling as well as changes in the expression of cardiac ion channels.

Echocardiographic Parameters Associated with Clinical Heart Failure Due to Partial Left Ventricular Unloading in Patients with Continuous-Flow LVAD

Purpose Patients with continuous-flow LVAD may develop clinical heart failure (HF) due to partial LV unloading. We aimed to examine clinical and echocardiographic predictors of HF defined by symptoms/signs and invasive hemodynamics. Methods and Materials Records of patients who received LVAD from 2008-12 in our center were reviewed. Patients with adverse events Results Of 140 patients who survived beyond 30 days post-LVAD, 11 (8%) had HF. Baseline pump speed (rpm) between subjects and controls: 9,091±466 vs 9,200±927. Patients with HF had higher echo-measured E/A ratio (2.0±1.1 vs 1.1±0.8, P=0.03) and right atrial pressure (RAP) (14.9±4.0 vs 5.0±1.3, P Conclusions Elevated E/A ratio and RAP, echo markers of diastolic dysfunction and high right-sided pressures, are associated with HF due to partial LV unloading in LVAD patients. These echo parameters may help guide diagnosis and appropriate management in this population. Echo parameters in LVAD patients with and without HF HF & PCWP ≥15 (N=11) No HF & PCWP P value RAP (mmHg) 14.9±4.0 5.0±1.3 E/A 2.0±1.1 1.1±0.8 0.03 E/e’ 15.3±4.1 11.1±4.7 0.05 E 88.8±26.9 66.6±25.1 0.06 LAVi (mL/m2) 34.1±13.4 24.3±8.6 0.06 TV PG (mmHg) 27.6±7.6 21.5±5.2 0.07 DT (ms) 179.9±48.4 194.5±66.9 0.5 E/A=Early/late mitral inflow, E/e’=Mitral early peak velocity/annular velocity, DT=Mitral deceleration time, LAVi=Left atrial volume index, RAP=Right atrial pressure, TV PG=Tricuspid pressure gradient

The Holy Grail of LVAD-induced reversal of severe chronic heart failure: the need for integration

This editorial refers to ‘Heart failure reversal by ventricular unloading in patients with chronic cardiomyopathy: criteria for weaning from ventricular assist devices’, by M. Dandel et al. doi:10.1093/eurheartj/ehq353 For a long time conventional wisdom had it that chronic severe heart failure is a unidirectional progressive disease which invariably results in death. This paradigm has dramatically changed with the demonstration that ‘prolonged’, near-complete unloading of the left ventricle (LV) with or without pharmacological therapy can result in sufficient clinical recovery in a variable percentage of patients to allow removal of the device with stable, normal or near-normal function over many years.1,2 This strategy avoids or delays transplantation and provides an innervated heart capable of providing normal power output3 and an improved quality of life. Surprisingly, this paradigm has been actively pursued in only very few centres, with varying rates of success in terms of both the percentage of patients who ‘recover’ and the period of sustained recovery.2,4 The field has been hampered by the availability of cardiac transplantation programmes in most centres performing left ventricular assist device (LVAD) implantations. Cardiac transplantation constitutes a validated form of treatment which obviates the need for repeated close observations to monitor recovery …

Heart failure reversal by ventricular unloading in patients with chronic cardiomyopathy: criteria for weaning from ventricular assist devices

AimsUnloading-promoted reversal of heart failure (HF) allows long-term transplant-free outcome after ventricular assist device (VAD) removal. However, because few patients with chronic cardiomyopathy (CCM) were weaned from VADs (the majority only recently), the reliability of criteria used for weaning decisions to predict long-term post-weaning success is barely known. After 15 years of weaning experience, we assessed this issue.Methods and resultsIn 47 patients with CCM as the underlying cause for HF, who were part of a total of 90 patients weaned from bridge-to-transplant-designed VADs since 1995, we analysed data on cardiac morphology and function collected before VAD implantation, echocardiographic parameters recorded during ‘off-pump’ trials, duration of HF before implantation, and stability of recovery before and early after VAD removal. Post-weaning 5 year freedom from HF recurrence reached 66%. Only five patients (10.6%) died due to HF recurrence or weaning-related complications. Pre-explantation off-pump left ventricular ejection fraction (LVEF) of ≥50 and ≥45% revealed predictive values for cardiac stability lasting ≥5 years after VAD removal of 91.7 and 79.1%, respectively. With each unit of LVEF reduction, the risk of HF recurrence became 1.5 times higher. The predictive value of LVEF ≥45% also became >90% if additional parameters like pre-explantation LV size and geometry, stability of unloading-induced cardiac improvement before VAD removal, and HF duration before VAD implantation were also considered. Definite cut-off values for certain parameters (including tissue-Doppler-derived LV wall motion velocity) allowed formulation of weaning criteria with high predictability for post-weaning stability, also in patients with incomplete cardiac recovery.ConclusionsVentricular assist device removal in CCM patients is feasible and can be successful even after incomplete cardiac recovery. Parameters of pre-explantation cardiac function, LV size and geometry, their stability during final off-pump trials, and HF duration allow detection of patients with the potential to remain stable for >5 post-weaning years.

Baseline left ventricular function and surgical annular stiffening to predict outcome and reverse left ventricular remodeling after undersized annuloplasty for intermediate-degree ischemic mitral regurgitation

We sought to identify determinants of clinical and functional outcome after myocardial revascularization and associated undersized annuloplasty in patients with intermediate-degree ischemic mitral regurgitation. Fifty-seven patients with 2+ or 3+ ischemic mitral regurgitation underwent coronary bypass surgery and implantation of undersized semirigid or flexible complete ring or autologous pericardial band and were followed up to 8.6 years. Operative mortality was 5%. Baseline left ventricular end-systolic volume index, the strongest multivariable predictor of early postoperative outcome, was correlated with end-systolic volume index (P < .001, R(2) = 0.67) and ejection fraction (P < .001, R(2) = 0.40) after repair. More compromised ejection fraction and end-systolic volume index predicted comparatively greater early functional improvement but higher residual postoperative end-systolic volume index (P < .01). Cox multivariable analysis identified wall motion as the best baseline predictor of late death and heart failure and regional inferoposterior wall motion as the strongest predictor of recurrent mitral regurgitation (P < or = .01). More rigid annuloplasty carried a higher probability of functional recovery in terms of ejection fraction, wall motion, and the occurrence and earlier timing of left ventricular reverse remodeling, expressed by different degrees of end-systolic volume index reduction (P < .001, hazard ratio >6). Combination of undersized mitral annuloplasty and coronary revascularization presents low operative mortality and determines left ventricular unloading in patients with intermediate-degree ischemic mitral regurgitation. Global and regional wall motion are powerful predictors of late outcome. Stiffer mitral annular repair promotes functional recovery and predicts higher probability and earlier timing of reverse remodeling.