Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.
DHZB Dienstleistungs GmbH, Berlin, Germany.
J Thorac Cardiovasc Surg. 2022 Dec;164(6):1922-1930.e2. doi: 10.1016/j.jtcvs.2021.01.001. Epub 2021 Jan 9.
Patients with a continuous-flow left ventricular assist device may show recovery of myocardial function with unloading. Identifying candidates for and predicting clinical and hemodynamic stability after left ventricular assist device explantation remain challenging.
Retrospective analysis of patients who underwent evaluation for left ventricular assist device explantation following a standardized protocol from January 2016 to March 2020. Patients who met screening criteria underwent echocardiography under "baseline," "minimal net flow," and "pump stop" conditions. If the protocol criteria were met, right heart catheterization with left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter were performed. In patients with pulmonary capillary wedge pressure less than 16 mm Hg, explantation was performed under "pump stop" conditions.
A total of 544 patients were screened. Of these, 57 (10.5%) underwent a total of 73 echocardiography under "baseline" "minimal net flow" and "pump stop" conditions and 46 underwent left ventricular assist device stoppage and occlusion of the outflow graft with balloon catheter maneuvers. Complications during the procedure were rare. Ultimately, 21 patients (3.9%) underwent explantation. The left ventricular ejection fraction at baseline was 55.5% ± 6.5%. The mean pulmonary capillary wedge pressure was 8.1 ± 2.6 mm Hg and increased to 10.7 ± 2.9 mm Hg under left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter. A nonischemic cause of cardiomyopathy was more likely to be found in patients who underwent explantation (20/21 patients [95%], P = .020). The survival 1 year after explantation was 95.2%, with 1 death occurring 222 days after left ventricular assist device explantation. At follow-up (median 24.9 months [interquartile range, 16.4-43.1 months]), patients were in New York Heart Association class 1 (61.9%), 2 (28.6%), and 3 (9.5%).
Our 4-year experience with a standardized protocol for left ventricular assist device explantation showed a low rate of adverse events. If all criteria are met, explantation can be performed safely and with an excellent survival and functional class.
带连续流左心室辅助装置的患者可能会在卸载后出现心肌功能恢复。确定左心室辅助装置移除的候选者并预测其临床和血流动力学稳定性仍然具有挑战性。
回顾性分析 2016 年 1 月至 2020 年 3 月期间按照标准化方案接受左心室辅助装置移除评估的患者。符合筛选标准的患者在“基线”、“最小净流量”和“泵停”条件下进行超声心动图检查。如果符合方案标准，则进行右心导管检查，并使用球囊导管停止左心室辅助装置和阻塞流出道移植物。如果肺毛细血管楔压低于 16mmHg，则在“泵停”条件下进行移除。
共筛选了 544 名患者。其中，57 名（10.5%）患者总共进行了 73 次“基线”、“最小净流量”和“泵停”条件下的超声心动图检查，46 名患者进行了左心室辅助装置停止和使用球囊导管阻塞流出道移植物的操作。手术过程中的并发症很少见。最终，21 名患者（3.9%）接受了移除。基线时左心室射血分数为 55.5%±6.5%。平均肺毛细血管楔压为 8.1±2.6mmHg，在左心室辅助装置停止和使用球囊导管阻塞流出道移植物时增加到 10.7±2.9mmHg。在接受移除的患者中，更有可能发现非缺血性心肌病的原因（21 名患者中的 20 名[95%]，P=0.020）。移除后 1 年的生存率为 95.2%，其中 1 例患者在左心室辅助装置移除后 222 天死亡。在随访（中位数 24.9 个月[四分位距，16.4-43.1 个月]）时，患者的纽约心脏协会功能分级为 1 级（61.9%）、2 级（28.6%）和 3 级（9.5%）。
我们在 4 年时间里按照标准化方案进行左心室辅助装置移除的经验表明，不良事件发生率较低。如果所有标准都得到满足，移除可以安全进行，并且具有极好的生存率和功能分级。
