Frazier O H, Baldwin Andrew C W, Demirozu Zumrut T, Segura Ana Maria, Hernandez Ruben, Taegtmeyer Heinrich, Mallidi Hari, Cohn William E
Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas.
Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas.
J Heart Lung Transplant. 2015 Jun;34(6):766-72. doi: 10.1016/j.healun.2014.09.015. Epub 2014 Sep 28.
The potential for myocardial reconditioning and device explantation after long-term continuous-flow left ventricular assist device (LVAD) support presents an opportunity to delay or avoid transplantation in select patients.
Thirty of 657 patients with end-stage heart failure supported with continuous-flow LVADs were assessed for device explantation. Each patient underwent an individualized process of weaning focused on principles of ventricular unloading, gradual reconditioning, and transition to medical therapy.
After varying reconditioning periods, 27 patients (16 men, 11 women; age, 39 ± 12 years) underwent LVAD explant, and 3 patients (2 men, 1 woman; age, 22 ± 6 years) were evaluated for explantation but could not be weaned. The duration of LVAD support was 533 ± 424 days (range, 42-1,937 days) for the explant cohort and 1,097 ± 424 days (range, 643-1,483) for the non-explant cohort. The LV end-diastolic dimension, LV ejection fraction, systolic pulmonary artery pressure, cardiac output, and cardiac index in the explant cohort were significantly improved at explantation (all, p < 0.05). Two late deaths occurred after LVAD explantation despite satisfactory native cardiac function, and 1 patient required resumption of LVAD support 2.7 years after device removal. The remaining explant patients remain in New York Heart Association classes I to II with medical management alone (mean survival post-explant, 1,172 ± 948 days). The 3 candidates who could not be weaned ultimately underwent transplantation.
The potential for recovery of native LV function after long-term continuous-flow LVAD support should encourage a more aggressive approach to ventricular reconditioning with the goal of device explantation and a return to medical management, particularly in young patients with dilated cardiomyopathy.
长期持续血流左心室辅助装置（LVAD）支持后心肌功能恢复及装置移除的可能性为部分患者延迟或避免心脏移植提供了契机。
对657例接受持续血流LVAD支持的终末期心力衰竭患者中的30例进行了装置移除评估。每位患者都经历了个体化的撤机过程，该过程侧重于心室卸载、逐步恢复及向药物治疗过渡的原则。
经过不同的恢复阶段后，27例患者（16例男性，11例女性；年龄39±12岁）接受了LVAD移除，3例患者（2例男性，1例女性；年龄22±6岁）接受了移除评估但无法撤机。移除组的LVAD支持时间为533±424天（范围42 - 1937天），未移除组为1097±424天（范围643 - 1483天）。移除组患者在移除时左心室舒张末期内径、左心室射血分数、收缩期肺动脉压、心输出量和心脏指数均有显著改善（均p < 0.05）。尽管术后心脏功能良好，但仍有2例患者在LVAD移除后晚期死亡，1例患者在装置移除2.7年后需要恢复LVAD支持。其余移除患者仅通过药物治疗维持在纽约心脏协会心功能I至II级（移除后平均生存时间1172±948天）。3例无法撤机的候选患者最终接受了心脏移植。
长期持续血流LVAD支持后左心室功能恢复的可能性应促使采取更积极的心室恢复方法，目标是移除装置并恢复药物治疗，尤其是对于患有扩张型心肌病的年轻患者。
