Abstract 12494: Optimal Timing for Echocardiographic Assessment of Left Ventricular Function During Reduced Left Ventricular Assist Device Support

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Ayesha Salahuddin ◽  
Kana Fujikura ◽  
Emma J Birks ◽  
Chris Cunningham ◽  
Faouzi Kallel ◽  
...  
Keyword(s):  
Heart Failure ◽  
Speckle Tracking ◽  
Circumferential Strain ◽  
Myocardial Function ◽  
Left Ventricular ◽  
Lv Function ◽  
Walk Test ◽  
Ventricular Assist ◽  
Full Support ◽  
Left Ventricular Assist

Introduction: In some circumstances left ventricular assist devices (LVAD) can be used to bridge patients with advanced heart failure to myocardial recovery or “remission”. Evaluation of the underlying myocardial function in patients supported with an LVAD is often performed with the pump speed turned down to minimal support for 15 minutes, to simulate unassisted ventricular loading conditions. Longer duration of reduced support and performance of exercise may allow for a more realistic evaluation of myocardial function to assess for recovery. Methods: Nine turn-down exams from 4 patients were analyzed. Subjects were participants in a multi-center prospective non-randomized study of LV recovery with HeartMate II LVAD together with a standardized protocol of pharmacological therapy (REmission from STAGE D Heart Failure (RESTAGE-HF)). LVEF and speckle tracking parameters were measured during full support, at 15 minutes of reduced support (6000 rpm) and again after a 6-min walk test. Averaged radial and circumferential strain, and global circumferential strain were analyzed from papillary muscle level short-axis view using speckle-tracking. Results: LV systolic parameters for each of these patients are shown, (Table). Improvement in LV function was not evident at 15 minutes of reduced support, compared to full support but was evident after the 6-min walk test. Conclusions: After 15 minutes of LVAD turndown, LV systolic parameters did not differ from full support values. Improvement in LV function compared to full support became evident when the protocol was extended to include imaging after a longer period of turndown with the addition of a 6-min walk test.

scholarly journals Prospective Multicenter Study of Myocardial Recovery Using Left Ventricular Assist Devices (RESTAGE-HF [Remission from Stage D Heart Failure])

Circulation ◽  
2020 ◽  
Vol 142 (21) ◽  
pp. 2016-2028 ◽  
Author(s):  
Emma J. Birks ◽  
Stavros G. Drakos ◽  
Snehal R. Patel ◽  
Brian D. Lowes ◽  
Craig H. Selzman ◽  
...  
Keyword(s):  
Heart Failure ◽  
Myocardial Function ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Assist Device ◽  
Ventricular Assist ◽  
Ventricular Ejection Fraction ◽  
Pulmonary Capillary ◽  
Left Ventricular Assist ◽  
Wedge Pressure

Background: Left ventricular assist device (LVAD) unloading and hemodynamic support in patients with advanced chronic heart failure can result in significant improvement in cardiac function allowing LVAD removal; however, the rate of this is generally considered to be low. This prospective multicenter nonrandomized study (RESTAGE-HF [Remission from Stage D Heart Failure]) investigated whether a protocol of optimized LVAD mechanical unloading, combined with standardized specific pharmacological therapy to induce reverse remodeling and regular testing of underlying myocardial function, could produce a higher incidence of LVAD explantation. Methods: Forty patients with chronic advanced heart failure from nonischemic cardiomyopathy receiving the Heartmate II LVAD were enrolled from 6 centers. LVAD speed was optimized with an aggressive pharmacological regimen, and regular echocardiograms were performed at reduced LVAD speed (6000 rpm, no net flow) to test underlying myocardial function. The primary end point was the proportion of patients with sufficient improvement of myocardial function to reach criteria for explantation within 18 months with sustained remission from heart failure (freedom from transplant/ventricular assist device/death) at 12 months. Results: Before LVAD, age was 35.1±10.8 years, 67.5% were men, heart failure mean duration was 20.8±20.6 months, 95% required inotropic and 20% temporary mechanical support, left ventricular ejection fraction was 14.5±5.3%, end-diastolic diameter was 7.33±0.89 cm, end-systolic diameter was 6.74±0.88 cm, pulmonary artery saturations were 46.7±9.2%, and pulmonary capillary wedge pressure was 26.2±7.6 mm Hg. Four enrolled patients did not undergo the protocol because of medical complications unrelated to the study procedures. Overall, 40% of all enrolled (16/40) patients achieved the primary end point, P <0.0001, with 50% (18/36) of patients receiving the protocol being explanted within 18 months (pre-explant left ventricular ejection fraction, 57±8%; end-diastolic diameter, 4.81±0.58 cm; end-systolic diameter, 3.53±0.51 cm; pulmonary capillary wedge pressure, 8.1±3.1 mm Hg; pulmonary artery saturations 63.6±6.8% at 6000 rpm). Overall, 19 patients were explanted (19/36, 52.3% of those receiving the protocol). The 15 ongoing explanted patients are now 2.26±0.97 years after explant. After explantation survival free from LVAD or transplantation was 90% at 1-year and 77% at 2 and 3 years. Conclusions: In this multicenter prospective study, this strategy of LVAD support combined with a standardized pharmacological and cardiac function monitoring protocol resulted in a high rate of LVAD explantation and was feasible and reproducible with explants occurring in all 6 participating sites. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01774656.

Abstract 17383: Total Left Ventricular Unloading with Impella® during Ischemia Reperfusion Minimizes Infarct Size, Preserves Left Ventricular Function and Prevents Chronic Heart Failure

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Takamoro Kakaino ◽  
Keita Saku ◽  
Takahiro Arimura ◽  
Takuya Akashi ◽  
Akiko Nishizaki ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Ischemia Reperfusion ◽  
Oxygen Demand ◽  
Chronic Phase ◽  
Left Ventricular ◽  
Lv Function ◽  
Ventricular Assist ◽  
Left Ventricular Assist ◽  
Acute Mi

Background: Despite marked advances of revascularization, acute myocardial infarction (MI) remains a major cause of chronic heart failure (CHF). Since excessive oxygen demand relative to supply is the fundamental mechanism of ischemia, we previously demonstrated, using a conventional left ventricular assist device (VAD), that total left ventricular (LV) unloading markedly reduced the MI size in ischemia reperfusion (IR) model through minimizing the myocardial oxygen consumption in acute experiment. The purpose of this investigation was to examine if the transvascular VAD, Impella®, could totally unload LV during IR and preserve LV function in chronic phase. Methods: We allocated 15 dogs into 3 groups, Sham (n=4), IR (n=6) and IR+Impella® (n=5). In IR and IR+Impella®, we ligated the left anterior descending artery for 180min through a left thoracotomy and then reperfused. In IR+Impella®, we introduced Impella® through the left subclavian artery from 60 min after the beginning of ischemia to 90 min after reperfusion. We then assessed LV function and MI size 4 weeks after IR injury. Results: Under Impella® support, LV pressure was much lower than arterial pressure indicating total LV unloading. In comparison with IR, Impella® significantly improved LV ejection fraction (2D-echo, Fig) (Sham 64±2.8, IR 48±3.1, IR+Impella® 64±1.2%, p=0.0007), lowered LVEDP (Sham 5.9±1.1, IR 16±3.7, IR+Impella® 4.3±0.87mmHg, p<0.05) and increased end-systolic elastance (sonomicrometric volumetry) (Sham 11±3.1, IR 5.7±1.5, IR+Impella® 12±1.6 mmHg/ml, p<0.05). Furthermore, Impella markedly reduced MI size (%LV circumferential area, IR 18±9.2, IR+Impella® 2.1±0.76%, p=0.0044, Fig) and decreased NT-proBNP (Sham 1004±462, IR 3385±677, IR+Impella® 1463±217pg/ml). Conclusions: Total LV unloading during IR with Impella® strikingly reduces MI size and preserves LV function in chronic phase. Impella® is a powerful tool in the management of acute MI in preventing CHF.

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