Ventricular assist device–promoted recovery and technical aspects of explant

Abstract

Feature Editor Note-Promoting left ventricular recovery after durable left ventricular assist device (LVAD) implantation remains a Holy Grail. Currently, less than 2% of patients exhibit signs of recovery after LVAD implantation, and even fewer tolerate device explantation without recurrence of heart failure. In this issue of the Journal, Drs Faerber and Doenst describe what we can do clinically to promote recovery, including how guidelinedirected medical therapy may facilitate structural remodeling of the unloaded heart. Identifying recovery in the presence of ventricular unloading also presents a challenge, and the authors describe weaning protocols for various devices. Current evidence suggests that there are clinical predictors of recovery, including younger age, nonischemic etiology, smaller left ventricular size, and shorter duration from diagnosis of heart failure, and these can be used to help draw our focus toward patients who are more likely to tolerate device weaning and explantation. In those patients, preparing for device explantation requires early surgical planning, often at the time of LVAD implantation, including correction of valvular lesions that will be hemodynamically significant in the absence of LVAD support.

Short-term outcomes of EXCOR Paediatric implantation

“…Thus, there should be no hesitation about a longer waiting time with VAD support if patient safety can be guaranteed. In addition to factors associated with VAD-promoted myocardial recovery in adults [ 23 ], age <2 years at VAD implantation, with a myocarditis diagnosis, and less myocardial fibrosis are thought to be predictors for recovery of left ventricular function during VAD support in children [ 14 , 24 ]. However, the specific factors that promoted late recovery in this study have not been identified.…”

Commentary: Mending a broken heart: The use of durable mechanical circulatory support

“…Faerber and colleagues 1 provide an expert review of the current state of using durable LVADs to promote myocardial recovery and achieve long-term freedom from heart failure. Faerber and colleagues 1 discuss a number of important conceptual and practical issues currently surrounding the use of durable LVADs to promote myocardial recovery.…”

“…Faerber and colleagues 1 provide an expert review of the current state of using durable LVADs to promote myocardial recovery and achieve long-term freedom from heart failure. Faerber and colleagues 1 discuss a number of important conceptual and practical issues currently surrounding the use of durable LVADs to promote myocardial recovery. First, although numerous studies have demonstrated improvement in the biology of the recovered heart associated with mechanical unloading, improvement in biology alone is insufficient to predict the degree of functional recovery or long-term freedom from heart failure.…”

Commentary: The waiting is the hardest part

“…The authors have put together a thorough document. 1 The road to myocardial recovery will be paved with a fundamental understanding of biology, innovative research on potential therapeutics, and the utility of chronic mechanical unloading.…”