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Review
. 2015 Jan;99(1):360-7.
doi: 10.1016/j.athoracsur.2014.07.061. Epub 2014 Nov 14.

Bridge to removal: a paradigm shift for left ventricular assist device therapy

Craig H Selzman  1 , Jesse L Madden  2 , Aaron H Healy  2 , Stephen H McKellar  2 , Antigone Koliopoulou  2 , Josef Stehlik  3 , Stavros G Drakos  3
Affiliations
Review

Bridge to removal: a paradigm shift for left ventricular assist device therapy

Craig H Selzman et al. Ann Thorac Surg. 2015 Jan.

Abstract

Ventricular assist devices have become standard therapy for patients with advanced heart failure either as a bridge to transplantation or destination therapy. Despite the functional and biologic evidence of reverse cardiac remodeling, few patients actually proceed to myocardial recovery, and even fewer to the point of having their device explanted. An enhanced understanding of the biology and care of the mechanically supported patient has redirected focus on the possibility of using ventricular assist devices as a bridge to myocardial recovery and removal. Herein, we review the current issues and approaches to transforming myocardial recovery to a practical reality.

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Figures

Figure 1
Figure 1
Bridge to removal. LVADs are placed in patients with pathologic remodeling and development of advanced heart failure. After implantation, the heart undergoes variable levels of reverse remodeling. If inadequate (non-responder), then continued support and/or transplantation remain the mainstay of therapy. If cellular, metabolic, architectural, and functional reversal occurs to normal, then these patients exhibit myocardial recovery. Another, perhaps more common group, are those patients that demonstrate functional improvement without structural and/or molecular normalization. These latter two groups (in orange) are both considered “responders” to therapy and are candidates for consideration of LVAD removal.
Figure 2
Figure 2
Highest left ventricular ejection fraction achieved after LVAD. (A) Highest EF achieved after LVAD unloading. (B) Changes in LVEF over time with highest EF achieved 30%–39% (group 3). (C) Changes in LVEF over time for patients with highest LVEF achieved >40% (group 4). Data is presented as percentages, means, and confidence intervals. *p<0.01 vs Pre-LVAD. Reproduced from [17] with permission.
Figure 3
Figure 3
Apical closure without plug. Intraoperative view demonstrating (A) primary closure associated with removal of the Jarvik 2000 Flowmaker LVAD. The prolene suture is seen as it goes through felt strips that include the flexible sewing ring. (B) Primary closure with felt strips following removal of the rigid HeartWare sewing ring. Notice the arterial cannula in the transected outflow graft.
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References

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