Can LVAD 'Bridge to Recovery' Be the Norm in Advanced HF?

Liam Davenport

April 20, 2017

NEWCASTLE UPON TYNE, UK — Many patients with advanced heart failure and a continuous-flow left-ventricular device (LVAD) who are weaned off the pump can achieve functional capacities in the normal or near-normal range, especially if they follow a "bridge-to-recovery" medical protocol designed to accelerate heart healing, suggests a small cohort study[1].

The research, published in the April 18, 2017 issue of the Journal of the American College of Cardiology, has some big limitations but is a further sign that bridging to recovery is a mainstream if not totally understood approach to patients on LVADs, in whom cardiac healing sufficient for explantation has long been observed.

Indeed, the quality of life and "physical endurance" of such patients taken off LVADs have seldom been studied in depth, writes Dr Abdallah G Kfoury (Intermountain Medical Center, Murray, UT) in an editorial accompanying the report[2] subtitled "Are we there yet?" His answer: "No, but almost."

In his editorial, Kfoury says that the new report, with Dr Djordje G Jakovljevic (Newcastle University, UK) as lead author, "provides reasonably convincing evidence that a sizable number of patients who had their LVADs explanted after recovery could attain cardiac and physical capacities near those of healthy individuals."

And that, he writes, "is not trivial. When pondering what determines acceptable benchmarks in the field, physical recovery has to be an imperative consideration in the general well-being of the patient."

Most Achieved Normal-Range Peak VO2

In the observational study based on 18 patients implanted with a continuous-flow LVAD, 16 who had an LVAD explanted, 24 heart-transplant candidates, and 97 healthy controls, explanted patients achieved cardiac and physical capacities comparable to healthy controls, with about four in 10 reaching normal range for peak cardiac power output and about two-thirds achieving normal-range peak VO2.

Proposing that central hemodynamic assessment via cardiopulmonary exercise stress testing can help identify early myocardial recovery in patients with LVADs, the researchers write. "More aggressive strategies to enhance cardiac remodeling and reconditioning during LVAD support should be encouraged, with ultimate goal of LVAD explantation and return to a pharmacological management."

The study participants—all of whom were men—underwent a maximal graded cardiopulmonary exercise test, with continuous respiratory gas-exchange measurements and the collection of noninvasive, rebreathing hemodynamic data.

The mean period of LVAD support for explanted patients was 396 days, and they were tested a mean of 3.3 years after explantation. The majority (87%) of explanted patients were in NYHA functional class 1 and the rest were in class 2.

Although all patients across the study achieved a respiratory exchange ratio of at least 1.10, with no significant difference between the groups, there were the expected significant differences in cardiac and physical functional capacities between healthy controls and the LVAD and heart-transplant groups.

The team found that peak exercise cardiac power output was significantly higher in healthy controls, at 5.35 W, and explanted LVAD patients, at 3.45 W, compared with implanted LVAD and heart-transplant patients at 2.37 W and 1.31 W, respectively (P<0.05).

Peak oxygen consumption was also significantly greater in healthy controls and explanted LVAD patients, at 36.4 mL/kg/min and 29.8 mL/kg/min vs 20.5 mL/kg/min and 12.0 mL/kg/min, respectively, in implanted LVAD and heart-transplant patients (P<0.05).

Furthermore, peak cardiac power output within the range of healthy controls was achieved by 38% of explanted LVAD patients, while 69% achieved a peak oxygen consumption within the healthy control range.

Early Preparation for LVAD Explantation?

"Taken together, these findings suggest that a significant number of LVAD explanted patients can achieve cardiac and functional capacity similar to healthy controls, confirming benefits of LVAD therapy and directing future investigations toward strategies to enhance myocardial recovery to allow for the device to be explanted," the group writes.

Speaking to heartwire from Medscape, Jakovljevic said that the findings do not address how long patients would need to have an LVAD implanted to experienced functional improvements.

"People who are implanted with an LVAD may have a different etiology of heart failure, different history of their disease, different age, and other factors that may influence the outcomes and recovery," he said. "In that sense, how long people should be supported is an individual thing."

Jakovljevic observed that more research is needed, saying: "The next step we are considering is that we would like to find potential predictors or markers that can inform us, in the early stages, which patients will respond to LVAD therapy." His group is looking for markers that "will clearly tell that a patient is ready for a pump to be implanted, or decommissioned, in some cases, as the patient is closer to recovery."

Jakovljevic is currently supported by Research Councils' UK Centre for Ageing and Vitality at Newcastle University; disclosures for the coauthors are listed in the paper. Kfoury has reported that he has no relevant financial relationships.

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