Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological Therapy: A Prospective Study

• Published in: Circulation (New York, N.Y.) N.Y.), 2011-02, Vol.123 (4), p.381-390
• Main Authors: BIRKS, Emma J, GEORGE, Robert S, DREYFUS, Gilles, KHAGHANI, Asghar, HEDGER, Mike, BAHRAMI, Toufan, WILTON, Penny, BOWLES, Christopher T, WEBB, Carole, BOUGARD, Robert, AMRANI, Mohammed, YACOUB, Magdi H
• Format: Article
• Language: English
• Subjects: Adult; Biological and medical sciences; Blood and lymphatic vessels; Blood. Blood coagulation. Reticuloendothelial system; Cardiology. Vascular system; Cardiomyopathy, Dilated - drug therapy; Cardiomyopathy, Dilated - therapy; Cardiovascular Agents - therapeutic use; Clenbuterol - therapeutic use; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Female; Heart Failure - drug therapy; Heart Failure - therapy; Heart-Assist Devices; Humans; Male; Medical sciences; Middle Aged; Pharmacology. Drug treatments; Prospective Studies; Severity of Illness Index; Stroke Volume - drug effects; Treatment Outcome; Ventricular Dysfunction, Left - drug therapy; Ventricular Dysfunction, Left - therapy; Young Adult
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.109.933960

We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices. We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, β-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the β₂-agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2 ± 12.6 years (16 male patients), patients were on 2.0 ± 0.9 inotropes, 7 (35) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39 ± 0.43 L · min⁻¹ · m⁻², pulmonary capillary wedge pressure was 31.5 ± 5.7 mm Hg, and heart failure history was 3.4 ± 3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2) were explanted after 286 ± 97 days. Eight had symptomatic heart failure for ≤6 months and 4 for >6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70 ± 7, left ventricular end-diastolic diameter was 48.6 ± 5.7 mm, left ventricular end-systolic diameter was 32.3 ± 5.7 mm, mV(O₂) was 21.6 ± 4 mL · kg⁻¹ · min⁻¹, pulmonary capillary wedge pressure was 5.9 ± 4.6 mm Hg, and cardiac index was 3.6 ± 0.6 L · min⁻¹ · m⁻². Estimated survival without heart failure recurrence was 83.3 at 1 and 3 years. After a 430.7 ± 337.1-day follow-up, surviving explants had an ejection fraction of 58.1 ± 13.8, left ventricular end-diastolic diameter of 59.0 ± 9.3 mm, left ventricular end-systolic diameter of 42.0 ± 10.7 mm, and mV(O₂) of 22.6 ± 5.3 mL · kg⁻¹ · min⁻¹. Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy.