Advertisement
The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Results of non-elective withdrawal of continuous-flow left ventricular assist devices in selected patients

  • Author Footnotes
    # These authors contributed equally to this work.
    Jan Knierim
    Correspondence
    Reprint requests: Jan Knierim, MD, Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Tel.: 49 30-45 93 2000. Fax.: +49 30-45 93 2100.
    Footnotes
    # These authors contributed equally to this work.
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany

    Department of Internal Medicine and Cardiology, Paulinenkrankenhaus Berlin, Berlin, Germany
    Search for articles by this author
  • Author Footnotes
    # These authors contributed equally to this work.
    Dmytro Tsyganenko
    Footnotes
    # These authors contributed equally to this work.
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
    Search for articles by this author
  • Julia Stein
    Affiliations
    DHZB Dienstleistungs GmbH, Berlin, Germany
    Search for articles by this author
  • Johanna Mulzer
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
    Search for articles by this author
  • Markus Müller
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
    Search for articles by this author
  • Yuriy Hrytsyna
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
    Search for articles by this author
  • Felix Schoenrath
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany

    DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany

    Department of Cardiovascular Surgery, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
    Search for articles by this author
  • Volkmar Falk
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany

    DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany

    Department of Cardiovascular Surgery, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany

    Department of Health Sciences and Technology, Translational Cardiovascular Technology, Eidgenössische Technische Hochschule Zürich, Zurich, Switzerland
    Search for articles by this author
  • Evgenij Potapov
    Affiliations
    Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
    Search for articles by this author
  • Author Footnotes
    # These authors contributed equally to this work.
Published:December 05, 2022DOI:https://doi.org/10.1016/j.healun.2022.11.008

      Background

      Protocols have been developed to identify patients for elective withdrawal of continuous-flow left ventricular device (cfLVAD) support. However, little is known about non-elective explantation or decommissioning of cfLVADs.

      Methods

      A retrospective analysis of all patients who underwent left ventricular assist device (LVAD) explantation or decommissioning at a single center between 2002 and 2021 was performed.

      Results

      Sixty-one patients underwent withdrawal of a cfLVAD (HeartMate II [Abbott] n = 17, HeartMate 3 [Abbott] n = 2, HeartWare HVAD [Medtronic] n = 36, INCOR [Berlin Heart] n = 6). The median follow-up after withdrawal was 1,039 days. The survival at 5 years was 76.1% (95% CI: 64.2%-95.2%). Predictors of worse outcomes in univariate regressive analysis were the duration of heart failure and the age at LVAD implantation. Of the 61 patients, 40 underwent elective withdrawal following a specific protocol. The other twenty-one patients underwent non-elective withdrawal of the cfLVAD because of device infection (n = 12), device thrombosis (n = 6), device malfunction (n = 2) or due to acute intracerebral bleeding (n = 1), also with an excellent survival at 5 years of 81.3%. (95% CI: 63.8-1). The withdrawal was performed in these patients even though they did not fulfill established criteria for successful explantation or decommissioning like clinical stability (n = 21), left ventricular end-diastolic diameter ≤ 55 mm (n = 3), performance of right heart catheterization (n = 6), or pulmonary artery wedge pressure ≤ 15 mm Hg (n = 3).

      Conclusion

      Non-elective withdrawal is possible in selected patients after discussion in a team of experienced cardiac surgeons, cardiologists, technicians, and VAD coordinators. The appropriate preoperative assessment before decommissioning or explantation of a cfLVAD warrants further investigation.

      KEYWORDS

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Heart and Lung Transplantation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Drakos SG
        • Mehra MR.
        Clinical myocardial recovery during long-term mechanical support in advanced heart failure: insights into moving the field forward.
        J Heart Lung Transplant. 2016; 35: 413-420https://doi.org/10.1016/j.healun.2016.01.001
        • Birks EJ
        • Tansley PD
        • Hardy J
        • et al.
        Left ventricular assist device and drug therapy for the reversal of heart failure.
        N Engl J Med. 2006; 355: 1873-1884https://doi.org/10.1056/NEJMoa053063
        • Birks EJ
        • Drakos SG
        • Patel SR
        • et al.
        A prospective multicentre study of myocardial recovery using left ventricular assist devices (REmission from Stage D Heart Failure: RESTAGE-HF): medium term and primary endpoint results.
        Circulation. 2020; https://doi.org/10.1161/CIRCULATIONAHA.120.046415
        • Dandel M
        • Weng Y
        • Siniawski H
        • et al.
        Heart failure reversal by ventricular unloading in patients with chronic cardiomyopathy: criteria for weaning from ventricular assist devices.
        Eur Heart J. 2011; 32: 1148-1160https://doi.org/10.1093/eurheartj/ehq353
        • Gerhard EF
        • Wang L
        • Singh R
        • et al.
        LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events.
        J Heart Lung Transplant. 2021; 40: 1560-1570https://doi.org/10.1016/j.healun.2021.08.001
        • Kanwar MK
        • Selzman CH
        • Ton VK
        • et al.
        Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support.
        J Heart Lung Transplant. 2022; S105324982201957Xhttps://doi.org/10.1016/j.healun.2022.05.015
        • Chaggar PS
        • Williams SG
        • Yonan N
        • Fildes J
        • Venkateswaran R
        • Shaw SM.
        Myocardial recovery with mechanical circulatory support: Myocardial recovery with MCS.
        Eur J Heart Fail. 2016; 18: 1220-1227https://doi.org/10.1002/ejhf.575
        • Knierim J
        • Heck R
        • Pieri M
        • et al.
        Outcomes from a recovery protocol for patients with continuous-flow left ventricular assist devices.
        J Heart Lung Transplant. 2019; 38: 440-448https://doi.org/10.1016/j.healun.2018.11.001
        • Frazier OH
        • Baldwin ACW
        • Demirozu ZT
        • et al.
        Ventricular reconditioning and pump explantation in patients supported by continuous-flow left ventricular assist devices.
        J Heart Lung Transplant. 2015; 34: 766-772https://doi.org/10.1016/j.healun.2014.09.015
        • Monteagudo Vela M
        • Rial Bastón V
        • Panoulas V
        • Riesgo Gil F
        • Simon A
        A detailed explantation assessment protocol for patients with left ventricular assist devices with myocardial recovery.
        Interact Cardiovasc Thorac Surg. 2021; 32: 298-305https://doi.org/10.1093/icvts/ivaa259
        • Hrytsyna Y
        • Kneissler S
        • Kaufmann F
        • et al.
        Experience with a standardized protocol to predict successful explantation of left ventricular assist devices.
        J Thorac Cardiovasc Surg. 2021; S0022522321000374https://doi.org/10.1016/j.jtcvs.2021.01.001
        • Dandel M
        • Weng Y
        • Siniawski H
        • et al.
        Pre-explant stability of unloading-promoted cardiac improvement predicts outcome after weaning from ventricular assist devices.
        Circulation. 2012; 126: S9-S19https://doi.org/10.1161/CIRCULATIONAHA.111.084640
        • Gyoten T
        • Rojas SV
        • Fox H
        • et al.
        Cardiac recovery following left ventricular assist device therapy: experience of complete device explantation including ventricular patch plasty.
        Eur J Cardiothorac Surg. 2021; 59: 855-862https://doi.org/10.1093/ejcts/ezaa461
        • Mulzer J
        • Faerber G
        • Kaufmann F
        • Potapov EV.
        Recovery plug for HeartMate 3 left ventricular assist device.
        J Thorac Cardiovasc Surg. 2019; 157: e35-e37https://doi.org/10.1016/j.jtcvs.2018.07.041
        • Potapov EV
        • Stepanenko A
        • Hennig E
        • Hetzer R
        • Krabatsch T.
        A titanium plug simplifies left ventricular assist device removal after myocardial recovery.
        J Heart Lung Transplant. 2010; 29: 1316-1317https://doi.org/10.1016/j.healun.2010.06.008
        • Potapov EV
        • Politis N
        • Karck M
        • et al.
        Results from a multicentre evaluation of plug use for left ventricular assist device explantation.
        Interact Cardiovasc Thorac Surg. 2021; : ivab344https://doi.org/10.1093/icvts/ivab344
        • Potapov EV
        • Schweiger M
        • Krabatsch T.
        Percutaneous balloon occlusion of a left ventricular assist device outflow cannula to facilitate evaluation of myocardial recovery.
        J Heart Lung Transplant. 2011; 30: 1300-1301https://doi.org/10.1016/j.healun.2011.07.007
        • Wever-Pinzon O
        • Drakos SG
        • McKellar SH
        • et al.
        Cardiac Recovery During Long-Term Left Ventricular Assist Device Support.
        J Am Coll Cardiol. 2016; 68: 1540-1553https://doi.org/10.1016/j.jacc.2016.07.743
        • Choi JH
        • Weber MP
        • Horan DP
        • et al.
        Left ventricular assist device decommissioning compared with explantation for ventricular recovery: a systematic review.
        ASAIO J. 2020; 66: 17-22https://doi.org/10.1097/MAT.0000000000000926