Antiplatelet and Anticoagulant Strategies Following Left Ventricular Assist Device (LVAD) Explantation or Decommissioning: A Scoping Review of the Literature

Deactivation of LVAD support for myocardial recovery-surgical perspectives

Left ventricular assist devices (LVADs) are excellent therapies for advanced heart failure patients either bridged to transplant or for lifetime use. LVADs also allow for reverse remodeling of the failing heart that is often associated with functional improvement. Indeed, growing enthusiasm exists to better understand this population of patients, whereby the LVAD is used as an adjunct to mediate myocardial recovery. When patients achieve benchmarks suggesting that they no longer need LVAD support, questions related to the discontinuation of LVAD therapy become front and center. The purpose of this review is to provide a surgical perspective on the practical and technical issues surrounding LVAD deactivation.

LVAD therapy as a catalyst to heart failure remission and myocardial recovery

The management of chronic heart failure over the past decade has witnessed tremendous strides in medical optimization and device therapy including the use of left ventricular assist devices (LVAD). What we once thought of as irreversible damage to the myocardium is now demonstrating signs of reverse remodeling and recovery. Myocardial recovery on the structural, molecular, and hemodynamic level is necessary for sufficient recovery to withstand explant and achieve sustained recovery post-LVAD. Guideline-directed medical therapy and unloading have been shown to aid in recovery with the potential to successfully explant the LVAD. This review will summarize medical optimization, assessment for recovery, explant methodologies and outcomes post-recovery with explant of durable LVAD.

Outcome of percutaneous HeartMate3 decommissioning: A single-centre experience

OBJECTIVES

To highlight the role of percutaneous left ventricular assist device (LVAD) decommissioning as a safe procedure after myocardial recovery in patients with advanced heart failure.

BACKGROUND

The HeartMate3 LVAD (Abbott, Chicago, IL, USA) is designed to provide circulatory support with enhanced hemocompatibility for patients with advanced heart failure. Most VADs are used as a bridge to heart transplantation; however, in certain cases, myocardial function recovers, and VADs can be explanted after the patient is weaned. Although surgical explantation remains the gold standard, minimally invasive percutaneous decommissioning has been described as a successful alternative. In this study, we present our experience, one-year outcomes, and adverse events associated with percutaneous LVAD decommissioning.

METHODS

We conducted a retrospective review of data from six consecutive patients who underwent percutaneous LVAD decommissioning.

RESULTS

Six patients were enrolled in the study. For all six patients, HM3 decommissioning was completed at least 6 months ago. No technical complications were documented. No strokes were observed within the study period, and the ejection fraction improved. The mean follow-up duration was 18 ± 8.5 months, and the survival rate was 100%.

CONCLUSION

Percutaneous HeartMate3 decommissioning appears to be safe. In particular, the survival after the procedure was 100%, and no events, especially thromboembolic ones, occurred.

Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar

As the prevalence of advanced heart failure continues to rise, treatment strategies for select patients include heart transplantation or durable left ventricular assist device (LVAD) support, both of which improve quality of life and extend survival. Recently, the HeartMate 3 has been incorporated into clinical practice, the United Network for Organ Sharing donor heart allocation system was revised, and the management of LVAD-related complications has evolved. Contemporary LVAD recipients have greater preoperative illness severity, but survival is higher and adverse event rates are lower compared with prior eras. This is driven by advances in device design, patient selection, surgical techniques, and long-term management. However, bleeding, infection, neurologic events, and right ventricular failure continue to limit broader implementation of LVAD support. Ongoing efforts to optimize management of patients implanted with current devices and parallel development of next-generation devices are likely to further improve outcomes for patients with advanced heart failure.

Biocompatibility of an apical ring plug for left ventricular assist device explantation: Results of a feasibility pre-clinical study

BACKGROUND

Patients receiving left ventricle assist devices (LVADs) as bridge to recovery remain a minority with 1%-5% of LVADs explanted after improvement of myocardial function. Nevertheless, considering the growing population of patients supported with LVADs, an increasing demand of new explantation strategies is expected in the near future. A novel plug for LVAD explantation has been developed and its biocompatibility profile needs to be proved. This study tested the biocompatibility of this novel plug in an in vivo ovine model.

METHODS

Six adult Blackhead Persian female sheep received plug implantation on the cardiac apex via minimally invasive approach and were clinically observed up to 90 days. Echocardiography was performed to detect thrombus formation or further plug-related complications. After the observation period, euthanasia was performed and samples including the plug and the surrounding tissues were obtained to be analyzed with correlative light and electron microscopy. Organ necrosis, ischemia and peripheral embolism were investigated.

RESULTS

Three animals survived surgery and completed the follow-up time without experiencing clinical complications. Echocardiographic controls excluded the presence of an intracavitary thrombus in the left ventricle (LV). Autopsy confirmed no signs of local infection, LV thrombus or peripheral embolism. Light and electron microscopy revealed an intact epithelium covering a layer of connective tissue on the plug surface facing the heart lumen.

CONCLUSIONS

This novel apical plug for LVAD explantation allows for endothelial and connective tissue growth on its ventricular side within 90 days from surgery. Further studies are required to fully demonstrate the biocompatibility of this apical plug and investigate the optimal anticoagulation regimen to be applied after implantation.