Mechanical Circulatory Support Devices as Destination Therapy
The possibility of weaning from the device should be considered, especially in DT patients. Despite initial encouraging attempts to wean patients from LVADs, the percentage of patients undergoing LVAD explantation for myocardial recovery remains very low (5–24%) and is only reported in small case series. Recent data from the INTERMACS registry report a decreasing percentage of a Bridge to Recovery (BTR) strategy for LVADs over the last years, below 1% for 2013. The highest recovery rate (73.3%) in patients with IDCM was published by Birks and colleagues using pulsatile-flow LVADs and treatment with clenbuterol. However, these data could not be reproduced by any other group. In a retrospective analysis of their MCS population from 1992 to 2009, Krabatsch et al. demonstrated that in 44 out of 387 patients with idiopathic dilated cardiomyopathy, LVAD explantation due to myocardial recovery was possible. Throughout this study, the initial weaning incidence was around 10.8% and the institutional weaning rate was 8.8%. The remaining 343 patients did not reach the institutional weaning criteria. In this trial, patients on pulsatile device had a threefold higher chance of weaning from an LVAD than with a non-pulsatile device. Younger patients had a significant better weaning rate than older patients (37.9±18.7 vs. 52.4±14.2 years). Although recovery after LVAD implantation is rare, Patel et al. demonstrated in a small single-arm prospective study with 21 patients that the combination of maximal neuro-hormonal blockade with heart failure medication and continuous-flow LVAD resulted in significant reverse remodelling. This process included a decrease in left atrial volume index and left ventricular internal diastolic diameter, and an increase in left ventricular ejection fraction. Although LVAD support could be weaned in only three patients, this study clarified that after LVAD implantation, optimization of the heart failure medication is necessary and should be continued in any case.
Recovery From LVAD
The possibility of weaning from the device should be considered, especially in DT patients. Despite initial encouraging attempts to wean patients from LVADs, the percentage of patients undergoing LVAD explantation for myocardial recovery remains very low (5–24%) and is only reported in small case series. Recent data from the INTERMACS registry report a decreasing percentage of a Bridge to Recovery (BTR) strategy for LVADs over the last years, below 1% for 2013. The highest recovery rate (73.3%) in patients with IDCM was published by Birks and colleagues using pulsatile-flow LVADs and treatment with clenbuterol. However, these data could not be reproduced by any other group. In a retrospective analysis of their MCS population from 1992 to 2009, Krabatsch et al. demonstrated that in 44 out of 387 patients with idiopathic dilated cardiomyopathy, LVAD explantation due to myocardial recovery was possible. Throughout this study, the initial weaning incidence was around 10.8% and the institutional weaning rate was 8.8%. The remaining 343 patients did not reach the institutional weaning criteria. In this trial, patients on pulsatile device had a threefold higher chance of weaning from an LVAD than with a non-pulsatile device. Younger patients had a significant better weaning rate than older patients (37.9±18.7 vs. 52.4±14.2 years). Although recovery after LVAD implantation is rare, Patel et al. demonstrated in a small single-arm prospective study with 21 patients that the combination of maximal neuro-hormonal blockade with heart failure medication and continuous-flow LVAD resulted in significant reverse remodelling. This process included a decrease in left atrial volume index and left ventricular internal diastolic diameter, and an increase in left ventricular ejection fraction. Although LVAD support could be weaned in only three patients, this study clarified that after LVAD implantation, optimization of the heart failure medication is necessary and should be continued in any case.