Left ventricular assist device-induced reverse remodeling: it’s not just about myocardial recovery

Abstract

Introduction The abnormal structure, function and molecular makeup of dilated cardiomyopathic hearts can be partially normalized in patients supported by a left ventricular assist device (LVAD), a process called reverse remodeling. This leads to recovery of function in many patients, though the rate of full recovery is low and in many cases is temporary, leading to the concept of heart failure remission, rather than recovery. Areas covered We summarize data indicative of ventricular reverse remodeling, recovery and remission during LVAD support. These terms were used in searches performed in Pubmed. Duplication of topics covered in depth in prior review articles were avoided. Expert Commentary Although most patients undergoing mechanical circulatory support (MCS) show a significant degree of reverse remodeling, very few exhibit sufficiently improved function to justify device explantation, and many from whom LVADs have been explanted have relapsed back to the original heart failure phenotype. Future research has the potential to clarify the ideal combination of pharmacological, cell, gene, and mechanical therapies that would maximize recovery of function which has the potential to improve exercise tolerance of patients while on support, and to achieve a higher degree of myocardial recovery that is more likely to persist after device removal.

Reducing regional flow stasis and improving intraventricular hemodynamics with a tipless inflow cannula design: An in vitro flow visualization study using the EVAHEART LVAD

“…Hypertension, diabetes, and thrombocytopenia are all risk factors for thrombus formation in heart failure patients, which are not accounted for in the mock circulatory loop studies. Long‐term remodeling is another significant challenge for predicting outcomes from in vitro studies, including the formation of pannus at the inflow cannula and LV volume reduction due to reverse remodeling . Thus, any trends indicated by experimental measurements must be validated with clinical outcomes.…”

“…Long-term remodeling is another significant challenge for predicting outcomes from in vitro studies, including the formation of pannus at the inflow cannula and LV volume reduction due to reverse remodeling. 2,3,8,9,22,54,55 Thus, any trends indicated by experimental measurements must be validated with clinical outcomes.…”

“…This site is vulnerable due to the disruption of the intraventricular flow pattern that leads to stasis in the gutter between the apical myocardium and the inflow cannula, especially at higher LVAD speeds and in hearts with poor apical contractility . Over time, tissue remodeling occurs, which can affect the flow architecture of the LV and potentially obstruct the inflow cannula …”

“…3,5 Over time, tissue remodeling occurs, which can affect the flow architecture of the LV and potentially obstruct the inflow cannula. [6][7][8][9] Clinical studies have found a strong correlation between inflow cannula positioning and thromboembolic events, and have identified best practices to minimize complications. 10,11 During placement of the LVAD, it is important to orient the inflow cannula to avoid obstruction, which can occur if the cannula is angled rather than parallel to the intraventricular septum.…”

Impact of left ventricular assist device therapy on the cardiac proteome and metabolome composition in ischemic cardiomyopathy

“…There are several studies demonstrating the improvement in cardiac function during LVAD therapy as part of reverse remodeling leading to cardiac recovery . The term reverse remodeling is understood as a complex multi‐level process involving genetic, proteomic, metabolomic, immunomodulatory, and neurohumoral changes that together underlie overall improvements in cardiac function . However, most studies reporting cardiac recovery during LVAD therapy focus on patients with non‐ischemic dilated cardiomyopathy (DCM).…”