Weaning from ventricular assist device support after recovery from left ventricular failure with or without secondary right ventricular failure

Abstract

Although complete myocardial recovery after ventricular assist device (VAD) implantation is rather seldom, systematic search for recovery is worthwhile because for recovered patients weaning from VADs is feasible and can provide survival benefits with long-term freedom from heart failure (HF) recurrence, even if a chronic cardiomyopathy was the primary cause for the drug-refractory HF necessitating left ventricular (LVAD) or biventricular support (as bridge-to-transplantation or definitive therapy) and even if recovery remains incomplete.LVAD patients explanted for myoacardial recovery compared to those transplanted from LVAD support showed similar survival rates and a significant proportion of explanted patients can achieve cardiac and physical functional capacities that are within the normal range of healthy controls. In apparently sufficiently recovered patients, a major challenge remains still the pre-explant prediction of the weaning success which is meanwhile reliably possible for experienced clinicians. In weaning candidates, the combined use of certain echocardiography and right heart catheterization parameters recorded before VAD explantation can predict post-weaning cardiac stability with good accuracy. However, in the absence of standardization or binding recommendations, the protocols for assessment of native cardiac improvement and also the weaning criteria differ widely among centers. Currently there are still only few larger studies on myocardial recovery assessment after VAD implantation. Therefore, the weaning practice relies mostly on small case series, local practice patterns, and case reports, and the existing knowledge, as well as the partially differing recommendations which are based mainly on expert opinions, need to be periodically systematised. Addressing these shortcomings, our review aims to summarize the evidence and expert opinion on the evaluation of cardiac recovery during mechanical ventricular support by paying special attention to the reliability of the methods and parameters used for assessment of myocardial recovery and the challenges met in both evaluation of recovery and weaning decision making.

A Multivariate Model to Predict Chronic Heart Failure after Acute ST-Segment Elevation Myocardial Infarction: Preliminary Study

“…Due to the lack of an accurate system for determining the risk of sudden death in such patients, implantation of a cardioverter defibrillator is not always properly performed [23][24][25]. Some researchers believe that a deeper investigation of the global strain characteristics would help unify the selection of patients [26,27]. Special attention is paid to the GLS parameter, since it has been established to be an indicator of an unfavorable course of CHF, and is associated with a decrease in the functional status of patients and an increase in the volume of the LV [28,29].…”

Ultrasound Assessment in Cardiogenic Shock Weaning: A Review of the State of the Art

“…Nevertheless, their removal does not have to be performed simultaneously. For instance, an awake ECMO strategy, with spontaneous patient breathing, is feasible and safe, being significantly associated with lower MV complication rates and short- and long-term mortality (61.9% vs. 26.7%) [ 8 , 9 , 10 ].…”

“…Echocardiography and right-heart catheterization are the cornerstone for hemodynamic assessment of myocardial improvement [ 8 ]. Moreover, lung and diaphragm ultrasound has emerged as a useful tool to predict outcomes of weaning in MV [ 11 ].…”

“…Moreover, lung and diaphragm ultrasound has emerged as a useful tool to predict outcomes of weaning in MV [ 11 ]. Although there is a lack of a gold standard [ 8 ], a broad range of helpful echocardiographic parameters enable an immediate, low-cost, and noninvasive bedside assessment for the best moment to wean the patient from circulatory and/or ventilatory support. Protocol-guided MV weaning has demonstrated a reduction in reintubation and post-extubation respiratory failure rates [ 12 ].…”

Echocardiography in Weaning Right Ventricular Mechanical Circulatory Support: Are We Measuring the Right Stuff?

“…Contradictory to previous studies, both TAPSE and severity of TR failed to predict weaning success. In patients who required temporary RV MCS after LVAD insertion Dandel et al, 40 formulated an estimate of RV functional reserve to anticipate the ability of the RV to adapt to an increase in load after MCS weaning: load adaptation index (LAI RV ). LAI RV = (VTI TR x RVED length ) / RVED area , where a LAI RV value  18 indicated normal RV adaptability.…”