Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin, Germany.
Eur Heart J. 2011 May;32(9):1148-60. doi: 10.1093/eurheartj/ehq353. Epub 2010 Oct 7.
Unloading-promoted reversal of heart failure (HF) allows long-term transplant-free outcome after ventricular assist device (VAD) removal. However, because few patients with chronic cardiomyopathy (CCM) were weaned from VADs (the majority only recently), the reliability of criteria used for weaning decisions to predict long-term post-weaning success is barely known. After 15 years of weaning experience, we assessed this issue.
In 47 patients with CCM as the underlying cause for HF, who were part of a total of 90 patients weaned from bridge-to-transplant-designed VADs since 1995, we analysed data on cardiac morphology and function collected before VAD implantation, echocardiographic parameters recorded during 'off-pump' trials, duration of HF before implantation, and stability of recovery before and early after VAD removal. Post-weaning 5 year freedom from HF recurrence reached 66%. Only five patients (10.6%) died due to HF recurrence or weaning-related complications. Pre-explantation off-pump left ventricular ejection fraction (LVEF) of ≥50 and ≥45% revealed predictive values for cardiac stability lasting ≥5 years after VAD removal of 91.7 and 79.1%, respectively. With each unit of LVEF reduction, the risk of HF recurrence became 1.5 times higher. The predictive value of LVEF ≥45% also became >90% if additional parameters like pre-explantation LV size and geometry, stability of unloading-induced cardiac improvement before VAD removal, and HF duration before VAD implantation were also considered. Definite cut-off values for certain parameters (including tissue-Doppler-derived LV wall motion velocity) allowed formulation of weaning criteria with high predictability for post-weaning stability, also in patients with incomplete cardiac recovery.
Ventricular assist device removal in CCM patients is feasible and can be successful even after incomplete cardiac recovery. Parameters of pre-explantation cardiac function, LV size and geometry, their stability during final off-pump trials, and HF duration allow detection of patients with the potential to remain stable for >5 post-weaning years.
在移除心室辅助装置 (VAD) 后，通过卸载促进心力衰竭 (HF) 的逆转可实现长期无需移植的结果。然而，由于只有少数慢性心肌病 (CCM) 患者能够成功脱离 VAD（大多数患者最近才开始），因此，用于脱机决策的标准的可靠性预测长期脱机后成功的能力几乎未知。在 15 年的脱机经验之后，我们评估了这个问题。
在因 CCM 导致 HF 而接受 VAD 治疗的 47 名患者中，这些患者是自 1995 年以来总共 90 名接受桥接移植设计的 VAD 脱机治疗的患者之一，我们分析了在 VAD 植入前收集的心脏形态和功能数据、在“无泵”试验期间记录的超声心动图参数、植入前 HF 的持续时间以及 VAD 移除前后的恢复稳定性。脱机后 5 年无 HF 复发的生存率达到 66%。仅有 5 名患者（10.6%）因 HF 复发或与脱机相关的并发症而死亡。脱机前的左心室射血分数（LVEF）≥50%和≥45%分别提示 VAD 移除后≥5 年心脏稳定性的预测值为 91.7%和 79.1%。LVEF 每降低 1 个单位，HF 复发的风险就会增加 1.5 倍。如果还考虑了脱机前的 LV 大小和几何形状、卸载诱导的心脏改善的稳定性以及 VAD 植入前 HF 的持续时间等其他参数，则 LVEF≥45%的预测值也会超过 90%。某些参数的明确截断值（包括组织多普勒衍生的 LV 壁运动速度）允许制定具有高预测性的脱机标准，即使对于不完全心脏恢复的患者也是如此。
在 CCM 患者中移除 VAD 是可行的，即使在不完全的心脏恢复后也可以取得成功。脱机前心脏功能、LV 大小和几何形状、在最后一次无泵试验期间的稳定性以及 HF 的持续时间等参数可检测出具有在脱机后 5 年以上保持稳定的潜力的患者。
