Left Ventricular Assist Device Decommissioning Compared with Explantation for Ventricular Recovery: A Systematic Review

Abstract

Left ventricular assist device (LVAD) withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. The aim of this systematic review was to examine the patient outcomes of device withdrawal via minimally invasive pump decommissioning as compared with reoperation for pump explantation. An electronic search was performed to identify all studies in the English literature assessing LVAD withdrawal. All identified articles were systematically assessed for inclusion and exclusion criteria. Overall, 44 studies (85 patients) were included in the analysis, of whom 20% underwent decommissioning and 80% underwent explantation. The most commonly used LVAD types included the HeartMate II (decommissioning 23.5% vs. explantation 60.3%; p = 0.01) and HeartWare HVAD (decommissioning 76.5% vs. explantation 17.6%; p < 0.001). At median follow-up of 389 days, there were no significant differences in the incidence of cerebrovascular accidents (p = 0.88), infection (p = 0.75), and survival (p = 0.20). However, there was a trend toward a higher recurrence of heart failure in patients who underwent decommissioning as compared with explantation (decommissioning 15.4% vs. explantation 8.2%, cumulative hazard; p = 0.06). Decommissioning appears to be a feasible alternative to LVAD explantation in terms of overall patient outcomes.

Ventricular assist device–promoted recovery and technical aspects of explant

“…7 However, the initial hope and excitement of this bridge to recovery (BTR) strategy was blunted by observations that BTR reflects a rare indication (1%-2%) and actual VAD explantations are uncommon (<2%). [8][9][10] Enthusiasm was further dampened when recurrence of heart failure after initially successful weaning was reported. 10 Yet, some centers focused on the weaning and explantation of VADs.…”

“…[8][9][10] Enthusiasm was further dampened when recurrence of heart failure after initially successful weaning was reported. 10 Yet, some centers focused on the weaning and explantation of VADs. 7,[11][12][13] They reported exceptionally high survival and low rates of heart failure recurrence in selected patients.…”

Echocardiographic Assessment of Left Ventricular Assist Device Outflow Velocity During Percutaneous Decommissioning

“…7 A systematic review of decommissioning, including limited reports of percutaneous approaches, compared with explantation on ventricular recovery, suggested that decommissioning is a promising modality of support withdrawal in patients with LVADs, with postoperative outcomes comparable to traditional explantation in regard to long-term survival. 8 After LVAD decommissioning, patients remain at risk for future decline in ventricular function despite recovery. In the INTERMACS registry at one-year after explantation, 18 of 21 patients were alive without further intervention, one had died, and two had undergone transplantation.…”

Clinical implications of LDH isoenzymes in hemolysis and continuous‐flow left ventricular assist device‐induced thrombosis

“…Blood pumps or continuous‐flow left ventricular assist devices (CF‐LVADs), either in the form of implantable or extracorporeal devices, have emerged as a promising therapeutic alternative for end‐stage heart failure . With growing utilization of CF‐LVADs for end‐stage heart failure, adverse events remain common leading to significant patient morbidity and mortality . One such major complication is pump thrombosis.…”

“…3,[8][9][10] With growing utilization of CF-LVADs for end-stage heart failure, adverse events remain common leading to significant patient morbidity and mortality. [11][12][13][14][15][16][17][18][19][20] One such major complication is pump thrombosis. The incidence of pump thrombosis has been estimated to be between 1.4% and 13.9%, and is largely dependent on the device.…”