Dandel Michael, Javier Mariano Francisco Del Maria, Javier Delmo Eva Maria, Loebe Matthias, Hetzer Roland
Department of Cardiology, Cardio Centrum Berlin, Berlin, Germany.
Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany.
Cardiovasc Diagn Ther. 2021 Feb;11(1):226-242. doi: 10.21037/cdt-20-288.
Although complete myocardial recovery after ventricular assist device (VAD) implantation is rather seldom, systematic search for recovery is worthwhile because for recovered patients weaning from VADs is feasible and can provide survival benefits with long-term freedom from heart failure (HF) recurrence, even if a chronic cardiomyopathy was the primary cause for the drug-refractory HF necessitating left ventricular (LVAD) or biventricular support (as bridge-to-transplantation or definitive therapy) and even if recovery remains incomplete. LVAD patients explanted for myoacardial recovery compared to those transplanted from LVAD support showed similar survival rates and a significant proportion of explanted patients can achieve cardiac and physical functional capacities that are within the normal range of healthy controls. In apparently sufficiently recovered patients, a major challenge remains still the pre-explant prediction of the weaning success which is meanwhile reliably possible for experienced clinicians. In weaning candidates, the combined use of certain echocardiography and right heart catheterization parameters recorded before VAD explantation can predict post-weaning cardiac stability with good accuracy. However, in the absence of standardization or binding recommendations, the protocols for assessment of native cardiac improvement and also the weaning criteria differ widely among centers. Currently there are still only few larger studies on myocardial recovery assessment after VAD implantation. Therefore, the weaning practice relies mostly on small case series, local practice patterns, and case reports, and the existing knowledge, as well as the partially differing recommendations which are based mainly on expert opinions, need to be periodically systematised. Addressing these shortcomings, our review aims to summarize the evidence and expert opinion on the evaluation of cardiac recovery during mechanical ventricular support by paying special attention to the reliability of the methods and parameters used for assessment of myocardial recovery and the challenges met in both evaluation of recovery and weaning decision making.
尽管心室辅助装置（VAD）植入后心肌完全恢复的情况相当少见，但系统地寻找恢复情况是值得的，因为对于恢复的患者，从VAD撤机是可行的，并且可以带来生存益处，长期免于心力衰竭（HF）复发，即使慢性心肌病是导致药物难治性HF并需要左心室辅助装置（LVAD）或双心室支持（作为过渡到移植或确定性治疗）的主要原因，即使恢复不完全。与从LVAD支持下接受移植的患者相比，因心肌恢复而移除LVAD的患者显示出相似的生存率，并且相当一部分移除LVAD的患者能够达到健康对照正常范围内的心脏和身体功能能力。在明显恢复充分的患者中，撤机成功的术前预测仍然是一个重大挑战，不过对于经验丰富的临床医生来说这是可以可靠做到的。在撤机候选患者中，VAD移除前记录的某些超声心动图和右心导管检查参数联合使用，可以较好地预测撤机后心脏稳定性。然而，由于缺乏标准化或有约束力的建议，各中心评估自身心脏改善情况的方案以及撤机标准差异很大。目前关于VAD植入后心肌恢复评估的大型研究仍然很少。因此，撤机实践主要依赖于小病例系列、当地实践模式和病例报告，现有的知识以及主要基于专家意见的部分不同建议需要定期进行系统化整理。针对这些不足，我们的综述旨在总结关于机械心室支持期间心脏恢复评估的证据和专家意见，特别关注用于评估心肌恢复的方法和参数的可靠性以及在恢复评估和撤机决策中遇到的挑战。
