Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support

Abstract

Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.

Keywords: GDMT; LVAD; clinical, remodeling; myocardial recovery.

Figure 1

Clinical considerations in using LVAD as bridge to recovery. GDMT, guideline directed medical therapy; LVAD, left ventricular assist device; LVEDD, left ventricular end diastolic dimension; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.

Figure 2

Clinical recommendations to promote myocardial recovery post LVAD implantation, ranging from pre-implant to explant. ACE, angiotensin converting enzyme inhibitor; AI, aortic insufficiency; ARB, angiotensin receptor blocker; BNP, brain natriuretic peptide; BPM, beats per minute; CPET, cardiopulmonary exercise test; CVP, central venous pressure; GFR, glomerular filtration rate; HF, heart failure; HR, heart rate; K, potassium; LVEDD, left ventricular end diastolic diameter; LVEF, left ventricular ejection fraction; LVESD, left ventricular end systolic dimension; MAP, mean arterial pressure; MR, mitral regurgitation; NICM, non-ischemic cardiomyopathy; PCWP, pulmonary capillary wedge pressure; RAAS, renin-angiotensin antagonist system; RHC, right heart catheterization.