Combining neurohormonal blockade with continuous-flow left ventricular assist device support for myocardial recovery: A single-arm prospective study

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Abstract

Background: Combining mechanical unloading by a continuous-flow left ventricular assist device (CF-LVAD) and neurohormonal blockade with heart failure medications (HFMED) is an underexplored clinical strategy to promote recovery of cardiac function in patients with advanced heart failure (HF). Methods: We implemented a clinical protocol to achieve maximal neurohormonal blockade after placement of a CF-LVAD and assessed its utility in an LVAD weaning (6,200 rpm) study. Thirty-four subjects were enrolled after CF-LVAD and were managed with aggressive, bi-weekly up-titration of HFMED. Results: Twenty-one subjects (8 with coronary artery disease, 13 with idiopathic dilated cardiomyopathy) were included in this LVAD weaning investigation. Overall, combined CF-LVAD and HFMED resulted in significant reverse remodeling with a decrease in left atrial volume index (44.7±16.0 to 31.6±12.1 ml/m2, p < 0.001) and LV internal diastolic diameter (6.7±1.5 to 6.0±1.6 cm, p = 0.003) and an increase in LV ejection fraction (17.4±6.5 to 33.1±16.2%, p < 0.001) during LVAD weaning (6,200 rpm). Five of 21 (24%) subjects demonstrated recovery of biventricular function. Exploratory analysis showed that recovered subjects had shorter duration HF, less myocardial fibrosis and less myocyte hypertrophy, and were supported at higher LVAD speeds. Conclusions: CF-LVAD support in combination with HFMED leads to significant reverse remodeling in patients with advanced HF. Using this approach, one quarter of patients demonstrated complete recovery of cardiac function. Our results suggest that bridge to recovery in the current device era is a clinically meaningful phenomenon and merits further investigation.

Original languageEnglish (US)
Pages (from-to)305-312
Number of pages8
JournalJournal of Heart and Lung Transplantation
Volume32
Issue number3
DOIs
StatePublished - Mar 2013

Fingerprint

Heart-Assist Devices
Heart Failure
Prospective Studies
Recovery of Function
Weaning
Equipment Failure
Dilated Cardiomyopathy
Clinical Protocols
Muscle Cells
Hypertrophy
Coronary Artery Disease
Fibrosis
Equipment and Supplies

Keywords

  • left ventricular assist device;recovery;
  • pharmacology;heart failure;
  • weaning study;neurohormonal blockade

ASJC Scopus subject areas

  • Transplantation
  • Cardiology and Cardiovascular Medicine
  • Pulmonary and Respiratory Medicine
  • Surgery

Cite this

@article{6ad81630931346939652dab302f405c7,
title = "Combining neurohormonal blockade with continuous-flow left ventricular assist device support for myocardial recovery: A single-arm prospective study",
abstract = "Background: Combining mechanical unloading by a continuous-flow left ventricular assist device (CF-LVAD) and neurohormonal blockade with heart failure medications (HFMED) is an underexplored clinical strategy to promote recovery of cardiac function in patients with advanced heart failure (HF). Methods: We implemented a clinical protocol to achieve maximal neurohormonal blockade after placement of a CF-LVAD and assessed its utility in an LVAD weaning (6,200 rpm) study. Thirty-four subjects were enrolled after CF-LVAD and were managed with aggressive, bi-weekly up-titration of HFMED. Results: Twenty-one subjects (8 with coronary artery disease, 13 with idiopathic dilated cardiomyopathy) were included in this LVAD weaning investigation. Overall, combined CF-LVAD and HFMED resulted in significant reverse remodeling with a decrease in left atrial volume index (44.7±16.0 to 31.6±12.1 ml/m2, p < 0.001) and LV internal diastolic diameter (6.7±1.5 to 6.0±1.6 cm, p = 0.003) and an increase in LV ejection fraction (17.4±6.5 to 33.1±16.2{\%}, p < 0.001) during LVAD weaning (6,200 rpm). Five of 21 (24{\%}) subjects demonstrated recovery of biventricular function. Exploratory analysis showed that recovered subjects had shorter duration HF, less myocardial fibrosis and less myocyte hypertrophy, and were supported at higher LVAD speeds. Conclusions: CF-LVAD support in combination with HFMED leads to significant reverse remodeling in patients with advanced HF. Using this approach, one quarter of patients demonstrated complete recovery of cardiac function. Our results suggest that bridge to recovery in the current device era is a clinically meaningful phenomenon and merits further investigation.",
keywords = "left ventricular assist device;recovery;, pharmacology;heart failure;, weaning study;neurohormonal blockade",
author = "Patel, {Snehal R.} and Omar Saeed and Sandhya Murthy and Vivek Bhatia and Shin, {Jooyoung (Julia)} and Dan Wang and Abdissa Negassa and Pullman, {James M.} and Goldstein, {Daniel J.} and Simon Maybaum",
year = "2013",
month = "3",
doi = "10.1016/j.healun.2012.11.019",
language = "English (US)",
volume = "32",
pages = "305--312",
journal = "Journal of Heart and Lung Transplantation",
issn = "1053-2498",
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TY - JOUR

T1 - Combining neurohormonal blockade with continuous-flow left ventricular assist device support for myocardial recovery

T2 - A single-arm prospective study

AU - Patel, Snehal R.

AU - Saeed, Omar

AU - Murthy, Sandhya

AU - Bhatia, Vivek

AU - Shin, Jooyoung (Julia)

AU - Wang, Dan

AU - Negassa, Abdissa

AU - Pullman, James M.

AU - Goldstein, Daniel J.

AU - Maybaum, Simon

PY - 2013/3

Y1 - 2013/3

N2 - Background: Combining mechanical unloading by a continuous-flow left ventricular assist device (CF-LVAD) and neurohormonal blockade with heart failure medications (HFMED) is an underexplored clinical strategy to promote recovery of cardiac function in patients with advanced heart failure (HF). Methods: We implemented a clinical protocol to achieve maximal neurohormonal blockade after placement of a CF-LVAD and assessed its utility in an LVAD weaning (6,200 rpm) study. Thirty-four subjects were enrolled after CF-LVAD and were managed with aggressive, bi-weekly up-titration of HFMED. Results: Twenty-one subjects (8 with coronary artery disease, 13 with idiopathic dilated cardiomyopathy) were included in this LVAD weaning investigation. Overall, combined CF-LVAD and HFMED resulted in significant reverse remodeling with a decrease in left atrial volume index (44.7±16.0 to 31.6±12.1 ml/m2, p < 0.001) and LV internal diastolic diameter (6.7±1.5 to 6.0±1.6 cm, p = 0.003) and an increase in LV ejection fraction (17.4±6.5 to 33.1±16.2%, p < 0.001) during LVAD weaning (6,200 rpm). Five of 21 (24%) subjects demonstrated recovery of biventricular function. Exploratory analysis showed that recovered subjects had shorter duration HF, less myocardial fibrosis and less myocyte hypertrophy, and were supported at higher LVAD speeds. Conclusions: CF-LVAD support in combination with HFMED leads to significant reverse remodeling in patients with advanced HF. Using this approach, one quarter of patients demonstrated complete recovery of cardiac function. Our results suggest that bridge to recovery in the current device era is a clinically meaningful phenomenon and merits further investigation.

AB - Background: Combining mechanical unloading by a continuous-flow left ventricular assist device (CF-LVAD) and neurohormonal blockade with heart failure medications (HFMED) is an underexplored clinical strategy to promote recovery of cardiac function in patients with advanced heart failure (HF). Methods: We implemented a clinical protocol to achieve maximal neurohormonal blockade after placement of a CF-LVAD and assessed its utility in an LVAD weaning (6,200 rpm) study. Thirty-four subjects were enrolled after CF-LVAD and were managed with aggressive, bi-weekly up-titration of HFMED. Results: Twenty-one subjects (8 with coronary artery disease, 13 with idiopathic dilated cardiomyopathy) were included in this LVAD weaning investigation. Overall, combined CF-LVAD and HFMED resulted in significant reverse remodeling with a decrease in left atrial volume index (44.7±16.0 to 31.6±12.1 ml/m2, p < 0.001) and LV internal diastolic diameter (6.7±1.5 to 6.0±1.6 cm, p = 0.003) and an increase in LV ejection fraction (17.4±6.5 to 33.1±16.2%, p < 0.001) during LVAD weaning (6,200 rpm). Five of 21 (24%) subjects demonstrated recovery of biventricular function. Exploratory analysis showed that recovered subjects had shorter duration HF, less myocardial fibrosis and less myocyte hypertrophy, and were supported at higher LVAD speeds. Conclusions: CF-LVAD support in combination with HFMED leads to significant reverse remodeling in patients with advanced HF. Using this approach, one quarter of patients demonstrated complete recovery of cardiac function. Our results suggest that bridge to recovery in the current device era is a clinically meaningful phenomenon and merits further investigation.

KW - left ventricular assist device;recovery;

KW - pharmacology;heart failure;

KW - weaning study;neurohormonal blockade

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SN - 1053-2498

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