Myocardial Recovery Strategy with Decommissioning for the HeartWare Left Ventricular Assist Device.
MacGowan Guy A,Wrightson Neil,Robinson-Smith Nicola,Woods Andrew,Parry Gareth,Gould Kate,Schueler Stephan
ASAIO journal (American Society for Artificial Internal Organs : 1992)
To manage myocardial recovery in patients with the HeartWare left ventricular assist device (HVAD), we describe a minimally invasive approach (decommissioning) that involves disconnecting the driveline and occluding the outflow tract through a small left thoracotomy incision, leaving the device in situ, in conjunction with optimal medical therapies and comprehensive assessment of left ventricular recovery. Nine patients (all male, 37 ± 12 years, all nonischemic dilated cardiomyopathy) had an HVAD implanted for 766 ± 343 days. When left ventricular function improved to mild impairment by echocardiography, patients underwent assessment at reduced flow (2578 ± 148 to 1822 ± 67 rpm) with documentation of compensated right heart hemodynamics and ejection fraction 52 ± 8%. Eight of nine patients underwent decommissioning, and 1 patient had a hybrid procedure of percutaneous occlusion of outflow graft and surgical division of driveline. Two patients died postoperatively at 413 days (sepsis) and 810 days (heart failure). In conclusion, in selected patients with nonischemic dilated cardiomyopathy, a prolonged period of HVAD support in conjunction with heart failure medications can lead to recovery of left ventricular function. Surgical decommissioning is then an option to remove these patients from support. These patients are, however, not cured and remain at risk for future deterioration in ventricular function and infections.
10.1097/MAT.0000000000000523
Decommission of a Heartmate 3 LVAD in a patient with left ventricular recovery.
Journal of cardiac surgery
BACKGROUND:Left ventricular assist devices (LVADs) have been a significant development in the treatment of patients with advanced heart failure supporting circulation as a bridge to transplant, recovery, or long-term destination therapy. When ventricular recovery occurs, there are multiple described ways of proceeding. HM2 decommissions are well described with varying degrees of explant operations, less so in HM3 due to the novelty of the device. In certain situations, invasive surgery can carry high risk and so a minimally invasive decommission, leaving the LVAD essentially intact in situ can be considered. CASE REPORT:In this report, we describe the case of a 35-year-old male diagnosed with an idiopathic dilated cardiomyopathy requiring an LVAD with subsequent identification of cardiac recovery with the asymptomatic thrombosis of the second HM3 device. Investigations demonstrated absent flow through the pump whilst the patient-reported NYHA I functional class symptoms. The Driveline was cut with the remaining internal pump components decommissioned and left in situ. At 1 year, the patient continues to do well with continued features of cardiac recovery with an LVEF of over 40%. CONCLUSION:LV recovery is well recognized with typical management being LVAD explant surgeries performed. Each case should be analyzed for risks and benefits to the patient and future research showed be directed towards levels of decommissioning surgery and management post-LVAD decommission patient care.
10.1111/jocs.17155
Echocardiographic Assessment of Left Ventricular Assist Device Outflow Velocity During Percutaneous Decommissioning.
Liu Xianying,Kimmelstiel Carey,Couper Gregory S,Brovman Ethan Y
Journal of cardiothoracic and vascular anesthesia
Left ventricular assist devices (LVADs) have been used as an effective therapeutic option in patients with advanced heart failure, either as a bridge to transplantation or, in some patients, as a bridge to recovery. LVAD withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. In this E-Challenge, the authors present a case of percutaneous decommissioning of an LVAD, in which TEE provided critical, real-time perioperative evaluation. The authors also review the current perspectives on LVAD decommissioning in terms of patient selection and surgical techniques.
10.1053/j.jvca.2020.12.043
Deactivation of LVAD support for myocardial recovery-surgical perspectives.
The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
Left ventricular assist devices (LVADs) are excellent therapies for advanced heart failure patients either bridged to transplant or for lifetime use. LVADs also allow for reverse remodeling of the failing heart that is often associated with functional improvement. Indeed, growing enthusiasm exists to better understand this population of patients, whereby the LVAD is used as an adjunct to mediate myocardial recovery. When patients achieve benchmarks suggesting that they no longer need LVAD support, questions related to the discontinuation of LVAD therapy become front and center. The purpose of this review is to provide a surgical perspective on the practical and technical issues surrounding LVAD deactivation.
10.1016/j.healun.2024.05.005
Antiplatelet and Anticoagulant Strategies Following Left Ventricular Assist Device (LVAD) Explantation or Decommissioning: A Scoping Review of the Literature.
Cowley Emily C,Yin Charles
Heart, lung & circulation
Mechanical circulatory support using left ventricular assist devices (LVADs) has transformed management of patients with end-stage heart failure with more patients on LVAD therapy surviving long enough to necessitate either device explantation or decommissioning. Usually, there is foreign material retained following these procedures that requires maintaining antiplatelet and/or anticoagulant therapy. However, there is no consensus on optimal management of antiplatelet and anticoagulant therapy following LVAD explantation or decommissioning. We conducted a scoping review of antiplatelet and anticoagulation strategies, searching EMBASE, PubMed and CENTRAL. A total of 15 case reports and series encompassing 38 patient cases were found that met inclusion criteria. There was a heterogeneity of LVAD types and techniques used for explantation and decommissioning. Most reports identified in our review maintained patients on a vitamin K antagonist for at least 3 months post-explantation or decommissioning with or without concomitant antiplatelet therapy with low-dose aspirin. However, there was no single agreed-upon optimal strategy for antiplatelet and anticoagulant use post-procedure. Factors such as the degree of foreign material retained following device explantation or decommissioning and whether there is another indication for anticoagulation or antiplatelet use must be considered. A lack of overall consensus indicates that more studies are needed in this area to establish definitive guidelines around antiplatelet and anticoagulant therapy following LVAD explantation or decommissioning.
10.1016/j.hlc.2021.04.004
LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events.
The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
BACKGROUND:Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown. METHODS:This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant. RESULTS:During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years. CONCLUSIONS:LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.
10.1016/j.healun.2021.08.001
How to remove the retroauricular driveline in the Jarvik 2000 after heart transplantation.
Gallo Michele,Bortolussi Giacomo,Bejko Jonida,Tarzia Vincenzo,Gerosa Gino,Bottio Tomaso
The International journal of artificial organs
The Jarvik 2000 is a left ventricular assist device (LVAD) used as either a bridge-to-transplant or destination therapy with the possibility of retroauricular percutaneous power delivery (pedestal). Percutaneous driveline infection in LVAD is a life-threatening complication that affects both the quality and length of life in patients. With its rigid fixation to the bone, the pedestal and the vascularity of scalp skin promote healing and reduce the risk of driveline infection. We describe a technique to remove the skull-mounted percutaneous pedestal of the Jarvik 2000 after heart transplantation.
10.5301/ijao.5000461
First successful percutaneous treatment of a totally occluded HeartWare outflow graft: Case report and literature review.
Kemaloğlu Cemal,Altekin Refik Emre,Bayezid Ömer
Anatolian journal of cardiology
As the number of implanted left ventricular assist devices (LVADs) used increases, the frequency of chronic complications encountered also increases. The pause of blood flow in the outflow graft is a rare, but fatal, complication. The aim of this article was to present the case of a patient in whom HeartWare outflow graft occlusion was removed by balloon angioplasty and to examine the treatment modalities of HeartWare outflow graft occlusions that have been percutaneously performed to date. The literature was searched for percutaneous interventions on outflow grafts of the left ventricular assist devices. The results of six patients who underwent interventions on outflow grafts were analyzed. Three of six patients with HeartWare outflow graft stenosis were treated with covered stents, while the remaining three were treated with bare metal stents. All procedures were applied successfully. Percutaneous interventions can be performed with appropriate equipment in patients with HeartWare outflow graft stenosis or total occlusion.
10.14744/AnatolJCardiol.2018.76736
Percutaneous Decommissioning 11 Years After Initial CF-LVAD Placement.
JACC. Case reports
An 80-year-old man with severe nonischemic cardiomyopathy status post left ventricular assist device (LVAD) placement 11 years prior presented for recurrent LVAD alarms from internal driveline fracture. Given his partial myocardial recovery and his preference to avoid surgical procedures, percutaneous LVAD decommissioning was performed by occlusion of the outflow graft and subsequently driveline removal. ().
10.1016/j.jaccas.2022.10.014
Outcome of percutaneous HeartMate3 decommissioning: A single-centre experience.
Artificial organs
OBJECTIVES:To highlight the role of percutaneous left ventricular assist device (LVAD) decommissioning as a safe procedure after myocardial recovery in patients with advanced heart failure. BACKGROUND:The HeartMate3 LVAD (Abbott, Chicago, IL, USA) is designed to provide circulatory support with enhanced hemocompatibility for patients with advanced heart failure. Most VADs are used as a bridge to heart transplantation; however, in certain cases, myocardial function recovers, and VADs can be explanted after the patient is weaned. Although surgical explantation remains the gold standard, minimally invasive percutaneous decommissioning has been described as a successful alternative. In this study, we present our experience, one-year outcomes, and adverse events associated with percutaneous LVAD decommissioning. METHODS:We conducted a retrospective review of data from six consecutive patients who underwent percutaneous LVAD decommissioning. RESULTS:Six patients were enrolled in the study. For all six patients, HM3 decommissioning was completed at least 6 months ago. No technical complications were documented. No strokes were observed within the study period, and the ejection fraction improved. The mean follow-up duration was 18 ± 8.5 months, and the survival rate was 100%. CONCLUSION:Percutaneous HeartMate3 decommissioning appears to be safe. In particular, the survival after the procedure was 100%, and no events, especially thromboembolic ones, occurred.
10.1111/aor.14279
Emergent percutaneous therapy for left ventricular assist device retrograde flow.
Wilson Ryan E,Gurley John C,Rajagopalan Navin,Tribble Thomas A
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
With the number of heart transplants being performed each year stagnating due to lack of donors the left ventricular assist device (LVAD) patient population will continue to grow. As more and more patients are living longer with LVADs, either as a bridge to transplant or destination therapy, we will continue to see an increased number of complications related to assist device therapy. One of the common challenges physicians face are patients who suffer from both bleeding and thrombotic complications. When bleeding complications occur anticoagulation is usually reduced or discontinued and then the thrombosis risk increases. Once a pump thrombosis occurs there are limited percutaneous treatment strategies available, especially in the setting of a recent bleeding event. Surgical exchange is the only definitive therapy and that can be a high risk and difficult operation. Turning off an LVAD may become necessary, as it did in our case, but that can lead to significant retrograde flow through the device and rapid patient decline. A prompt percutaneous therapy is needed to stabilize these patients.
10.1002/ccd.27414
Left Ventricular Assist Device Percutaneous Deactivation With a Watchman Device.
Aoun Tanous,Baudry Guillaume,Rioufol Gilles,Obadia Jean Francois,Pozzi Matteo
The Annals of thoracic surgery
Myocardial recovery in patients with left ventricular assist devices is a rare event. Surgical explantation remains a risky and challenging procedure. Alternative percutaneous techniques could represent an effective solution. This report describes the clinical use of a Watchman closure device (Boston Scientific Corp, Marlborough, MA) in deactivation of a HeartMate 3 left ventricular assist device (Abbott Laboratories, Abbott Park, IL).
10.1016/j.athoracsur.2020.11.051
The effect of standardization of insertion and removal of percutaneous left ventricular assist device.
Cardiovascular revascularization medicine : including molecular interventions
BACKGROUND:The effect of standardizing an insertion and removal protocol for pVAD devices has not been previously described. OBJECTIVES:We sought to evaluate clinical outcomes in patients who underwent pVAD insertion pre- and post-protocol standardization. METHODS:All patients who underwent pVAD insertion that remained in place at index procedure completion between January 2017 and September 2023 at a single academic center for both high-risk PCI and cardiogenic shock indications were included in the study. The primary outcome was the incidence of limb ischemia and major bleeding before and after the protocol initiation. Secondary outcomes included in-hospital and 30-day MACCE rate (death, myocardial infarction, stroke, emergent CABG), and how often the operators followed the protocol. RESULTS:A total of 89 patients had pVAD left in place (29 pre-protocol initiation and 60 post-protocol initiation). There was a significant decrease in incidence of limb ischemia post-protocol initiation compared to pre (17.2 % vs 1.7 %, p = 0.01) but no difference in bleeding incidence (13.8 % vs 20.0 %, p = 0.47). Adherence increased in all components of the protocol except for right heart catheterization. CONCLUSION:Standardization of an insertion and removal protocol for pVAD devices led to a statistically significant decrease in limb ischemia in a high-risk patient population.
10.1016/j.carrev.2024.05.035
Cerebral protection during percutaneous intervention for left ventricular assist device outflow graft obstruction.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
BACKGROUND:Left ventricular assist devices (LVAD) outflow graft obstruction is an uncommon complication but carries significant morbidity and mortality. Here we provide a case series of patients with LVAD intrinsic outflow graft obstruction who are deemed to be a high surgical risk for pump exchange and, therefore, underwent percutaneous intervention with the concomitant use of neuroprotective device-Sentinel cerebral protection system (CPS) (Boston Scientific) to prevent embolic stroke. METHODS:We retrospectively analyzed patients who underwent LVAD placement in our institution and developed LVAD outflow graft obstruction. The diagnosis of LVAD outflow graft obstruction was confirmed by utilizing various cardiac imaging modalities such as echocardiography and/or computed tomography angiography. All patients were treated with percutaneous intervention and a catheter-based CPS. RESULTS:From a total of 501 LVAD implants in our institute, 6 (1.2%) patients with LVAD outflow graft obstruction who underwent percutaneous treatment were included; 4 patients with HeartMate-III LVAD, 1 patient with HeartMate-II LVAD, and 1 patient with HeartWare (HVAD). The median age of patients was 56.5 years at the time of LVAD implantation. The median time from the LVAD implantation to the episode of LVAD outflow obstruction was 1343 days. Utilization of Sentinel CPS resulted in the capture and removal of thrombus/debris in all patients. CONCLUSIONS:Percutaneous intervention of LVAD outflow graft obstruction is less invasive than surgical pump exchange and an acceptable alternative in properly selected patients. In our experience, utilization of a catheter-based CPS can help in reducing the incidence of periprocedural embolic events.
10.1002/ccd.30241
Percutaneous Decommissioning of Left Ventricular Assist Device.
Soon Jia-Lin,Tan Ju-Le,Lim Choon-Pin,Tan Teing-Ee,Tan Swee-Yaw,Kerk Ka-Lee,Sim Kheng-Leng David,Sivathasan Cumaraswamy
Heart, lung & circulation
BACKGROUND:The left ventricular assist device (LVAD) has revolutionised our treatment of advanced stage heart failure, giving debilitated patients a new lease on life. A small proportion of these LVAD patients can be bridged-to-recovery. The identification of these patients and decision to wean, however, can be challenging. METHODS:The need to fully explant the device upon recovery has evolved to a minimalist approach aiming to avoid injury to the 'recovered' heart. A review of the evolution of explant strategies was performed to guide our decision to wean the LVAD in our early experience. RESULTS:Between 2009 and 2014, two patients in our series of 69 LVAD implants (2.9%) were successfully weaned off their LVADs. The second patient had a minimal access implantation of his HeartWare Ventricular Assist Device (HVAD, Medtronic Inc, Framingham, MA, USA). His clinical variables and minimalist weaning strategy are described. CONCLUSIONS:A case of LVAD decommissioning by thrombosis of the outflow graft, using percutaneous Amplatzer Vascular Plug II (St. Jude Medical, St. Paul, MN, USA) without surgery is reported.
10.1016/j.hlc.2017.07.011
Percutaneous approach to left ventricular assist device decommissioning.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
OBJECTIVE:To assess the outcomes of a single-center experience with percutaneous left ventricular assist device (LVAD) decommissioning. BACKGROUND:Patients with LVADs may eventually require their removal, either due to recovery of left ventricular function or recurrent complications. Traditionally, withdrawal of LVAD support has been managed with surgical device explantation, which carries significant procedural risks. Transcatheter LVAD decommissioning, with outflow graft occlusion and driveline transection, has recently been described as an alternative to surgical removal. METHODS:Here, we report on a retrospective cohort of five consecutive cases treated with transcatheter LVAD decommissioning. RESULTS:The procedure was effective in all cases, and no patient experienced procedure-related complications. At midterm follow-up, the three patients who had myocardial function recovery were alive and had not experienced heart failure-related symptoms or complications. CONCLUSION:Percutaneous LVAD decommissioning appears to be a safe and effective approach to LVAD treatment discontinuation.
10.1002/ccd.30230