Myocardial Recovery is Possible After LVAD Implantation for Heart Failure

This Clinician’s View is written by Andrija Vidic, DO, System Medical Director for Heart Failure and Cardiac Transplantation, AdventHealth Transplant Institute.

The first left ventricular assist device (LVAD) was approved over three decades ago to serve as a bridge-to-transplant therapy for patients experiencing advanced, end-stage heart failure. Then in 2003, LVAD was approved as a long-term, “destination” therapy for certain patients with advanced heart failure who are not eligible to receive a heart transplant or choose not to do so. This surgically implanted, battery-operated mechanical pump helps a patient's weakened left ventricle effectively pump oxygenated blood to the rest of the body. Once implanted, the LVAD has a drive line that typically comes out of the abdomen and must always be connected to an external controller and power source, requiring electricity and rechargeable batteries.

About 4,000 LVADs are implanted across the United States every year, and most stay implanted for the remainder of the patient’s life unless removed for a transplant. As one of the busiest LVAD programs in the country, AdventHealth has been the first and only hospital in the state of Florida to join an international consortium led by Stavros Drakos, MD, PhD, at the University of Utah Health & School of Medicine. Called the Myocardial Recovery International Network, this group has been carefully exploring and refining a new frontier: LVAD-mediated recovery.

AdventHealth Cardiothoracic Surgeon Ahmad Zeeshan, MD, and myself have been actively involved in the consortium’s work. We now know that approximately 10 to 20% of patients who receive LVAD can gain enough return of cardiac function that we can slowly wean them off the LVAD therapy, either by removing the device or making it inactive, eliminating the need for immunosuppression or a heart transplant and significantly improving quality of life. In fact, for these select patients, we can achieve long-term outcomes similar to those achieved through heart transplant. In one recent study, with follow-up extending up to 4 years after LVAD explant, approximately 70% of the patients were free from heart failure relapse events.

Through the consortium, we are participating in a multi-center VAD Wean Registry and collaborated to develop the RecoverHeart Calculator, a tool that provides personalized predicted recovery probability for LVAD patients to help identify the best candidates for this bridge-to-recovery (device removal) approach.

Paving a Pathway for Myocardial Recovery

A Working Group of the National Heart, Lung and Blood Institute first established a working definition of cardiac recovery in 2016: “a reversal of the pathological state of the myocardium with significant improvement in cardiac structure and function sufficient to achieve a sustained remission from recurrent heart failure events.”

Myocardial recovery involves a mechanical unloading of the heart combined with aggressive medical management and is also called reverse remodeling. When a patient initially presents to our team, they are in end-stage heart failure with low blood pressure and unable to tolerate medical therapy. This could be due to an acute or chronic event. After an LVAD is implanted, their blood pressure improves, and we can add medical therapy while monitoring them for improvement. Over the course of a year or two, when the stressor that caused their initial heart failure is gone, some patient’s hearts progressively get better. For example, if a patient’s heart failure was due to a nonischemic dilated cardiomyopathy, and we place a LVAD and support with medical therapy, we often see myocardial recovery, including improvement in ejection fraction, to the point we can consider weaning them off the LVAD.

At AdventHealth, we now screen all patients who have LVAD to see if there is improvement in their heart function over time. For those who meet the criteria, the recovery and weaning process is gradual, implemented through a precise clinical protocol and carefully monitored through extensive testing. This includes echocardiography, hemodynamic assessment through right heart catheterization, and functional capacity evaluation in the form of cardiopulmonary exercise and stress testing. Once the heart is fully functioning for an established period and all parameters have been met, we work with our surgeons to either remove the LVAD or decommission it, meaning the LVAD remains in place inside the body but no longer functions.

Collaborating to Develop Best Practices and Set Care Standards

Our work with the international consortium and the VAD Wean Registry has been essential to advancing the practice of myocardial recovery and achieving the best possible patient outcomes. The consortium began in 2019, and AdventHealth was one of the first programs to join. We're exchanging ideas with other programs around the country who are enthusiastic about this process, and together, we have established protocols to achieve consistency and a registry to gather and analyze long-term outcomes. The VAD Wean Registry now includes over 40 adult and pediatric sites and more than 800 patients, including three from AdventHealth who have been explanted from LVAD with two additional patients who will be enrolled. The data we are collecting is improving our understanding and helping to refine patient management strategies.

Identifying Candidates for LVAD Myocardial Recovery

One of the most exciting developments that has emerged through AdventHealth’s work with the consortium and registry is the development of the RecoverHeart Calculator, a multicenter model to determine the individualized probability of myocardial recovery. It evaluates prognostic factors, including four routinely available clinical variables:

• Sex
• Non-ischemic cardiomyopathy
• Duration of heart failure (months)
• Preoperative echo left ventricular end-diastolic diameter (LVEDD)

The calculator computes a personalized predicted recovery probability percentage, allowing us to identify patients best suited for the myocardial recovery program and improving underutilization of LVAD as a bridge to cardiac recovery. The multicenter cohort study that evaluated the RecoverHeart calculator and validated it as a prognostic tool was recently presented at the European Society of Cardiology meeting and is currently under review for the European Heart Journal.

Building a Better Future for Patients with Heart Failure

The goal of AdventHealth’s Myocardial Recovery Program is to prevent recurrence of heart failure while restoring quality of life. We’re excited about how many patients we have already saved from needing heart transplants, and we’re committed to continuing to grow our knowledge base and to build awareness of this underutilized approach. Additionally, through the consortium, many other studies are underway to better understand the mechanisms of cardiac recovery and to develop novel heart failure therapies. Our work is not finished, and we plan to remain on the forefront, pioneering new evidence-based approaches that will help our patients feel whole.