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Myocardial Recovery and LVAD Explant: A Case Study

Meaghan R. Young, MSN, AG‐ACNP‐BC, CCTC, CHFNMohammad Abuannadi, MDDivision of Cardiovascular Medicine Department of Advanced Heart Failure/TransplantSeptember 9, 2021

Case Study

• 31 yo F, PMH NICM and LV thrombus admitted to OSH with bilateral pleural effusions and presumed decompensated HF (treated for pneumonia as CTPA significant for possible empyema)

• TTE with LVEF 30-35%, LV apical thrombus and estimated PA systolic 75 mmHg

• Transferred to UVa for further work-up and evaluation for NICM and likely WHO Group II Pulmonary HTN

Any pictures included were provided to me by the patient and permission was given to use in this presentation. 

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Initial Presentation

• Presented to OSH 5 months prior with severe cough

• Found then to have LVEF 35-40%, LV thrombus and pneumonia

• Placed on LifeVest and discharged on Metoprolol, Entresto, Spironolactone, Ivabridine

• Returned 4 months later with recurrent cough and worsening dyspnea

• Unable to walk short distances without dyspnea

• Nightly PND and 2-3 pillow orthopnea

• Worsening abdominal bloating and bilateral LE edema

• Frequent palpitations

Admission Vitals

• HR 129, Sinus Tachycardia

• BP 111/58

• O2 sats 100% on Room Air

• RR 22

• Temperature 36.6 C Oral

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Admission Laboratories

• BNP 1727

• TBili 1.3

• Lactic Acid 2.7 progressed quickly to 7.1 overnight

• Normal renal function

• Hgb 8.3 (labs confirming IDA)

• WBC 8.3

• Na 138

• INR 2.0 (on Warfarin)

‐Cardiomegaly and pulmonary edema

‐Moderate layering R pleural effusion

‐Trace L pleural effusion

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Transthoracic ECHO

• LVEF 30-35% with apical thrombus

• LVEDd 5.18 cm, mildly dilated

• RVEDd 3.4 cm, mildly dilated, moderately reduced function

• Severe TR, dilated annulus with partially flail lateral leaflet, evidence of severe PA systolic elevation

• Moderate to severe MR with mild thickening of the leaflets

• IVC 2.52 cm

• XERO Viewer (virginia.edu)

Course of Events• Diuresed on arrival with IV Furosemide

• Worsening lactic acidosis, tachypnea and tachycardia

• Transfer to ICU, inotropes initiated, IV diuresis continued

• Pulmonary status worsened, R thoracentesis 740 ml serous fluid

• Hemodynamics worsened on dual inotropes (Dobuta 10 and Milrinone 0.5), considered for temporary mechanical support but declined given RV failure

• Cannulated for VA ECMO and listed Status 1 for heart transplant

• Required PLEX/IVIG given elevated PRA 99% but contributed to Klebsiella bacteremia

• Bleeding at ECMO cannulation site, developed Staph capitus and epidermidis bacteremia

• Decision made for HVAD implant and TV repair

• Long and complicated ICD stay, but made recovery and discharged home 3 weeks post operatively

• Listed Status 4 for heart transplant upon discharge

• LVEF at time of discharge 20-25%, RV severely dilated and severely reduced,

no TR

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Right Heart Catheterization

• RA 12 mmHg

• RV 55/3 mmHg

• PA 59/30 with PA Mean 40 mmHg

• PCWP 18

• PA sat 50%

• CO 4.4-5.6 LPM, CI 2.5-3.2

• On Dobutamine 5 mcg/kg/min

Course of Events• Diuresed on arrival with IV Furosemide

• Worsening lactic acidosis, tachypnea and tachycardia

• Transfer to ICU, inotropes initiated, IV diuresis continued

• Pulmonary status worsened, R thoracentesis 740 ml serous fluid

• Hemodynamics and symptoms worsened on dual inotropes (Dobuta 10 and Milrinone 0.5), considered for temporary mechanical support but declined given RV failure

• Cannulated for VA ECMO and listed Status 1 for heart transplant

• Required PLEX/IVIG given elevated PRA 99% but contributed to Klebsiella bacteremia

• Bleeding at ECMO cannulation site, developed Staph capitus and epidermidis bacteremia

• Decision made for HVAD implant and TV repair

• Long and complicated ICD stay, but made recovery and discharged home 3 weeks post operatively

• Listed Status 4 for heart transplant upon discharge

• LVEF at time of discharge 20-25%, RV severely dilated and severely reduced,

no TR

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Discharge Medications

• Metoprolol XL 100 mg daily

• Bumetanide 2 mg daily

• Aspirin 325 mg daily

• Warfarin for INR goal 2-3

• IV Ceftriaxone and Vancomycin for multiple bacteremias

*LVEF at time of discharge 20-25%, RV severely dilated and severely reduced function, no TR

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Post VAD Admission # 1

• Admitted 10 days after initial discharge for persistent and productive cough

• Found to have Enterobacter cloacae and lactobacillus species from LLL abscess and empyema, treated with 6 weeks Vanc/Zosyn

- TTE x 2 during admission showed LVEF 20-25%, RV severely dilated and severely reduced function, no TR with St. Jude Bioprosthetic valve present and functioning normally, mild MR

- Discharged on Metoprolol XL 100 mg daily and Lisinopril 5 mg daily added

First Clinic Visit

• Still with dry cough, but improving

• Symptomatically feeling better from HF standpoint

• Lisinopril had been held due to cough

• Spironolactone 25 mg daily started

• Bumetanide reduced to 1 mg daily

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Post VAD Admission # 2

• Admitted with AKI, nausea, vomiting and diarrhea, likely related to Vancomycin nephrotoxicity

• Spironolactone HELD

• Hydralazine 100 mg TID added

• Metoprolol XL 100 mg daily continued

• Bumetanide PRN

• Renal function improved upon discharge

INTERMACS Cardiac Recovery Score (I-CARS)

• University of Utah study evaluated true incidence of cardiac recovery in ~14,000 patients from INTERMACS data who received a LVAD

• Predictive model of cardiac recovery led to creation of I-CARS score

• I-CARS score >/= 7: high probability of myocardial recovery, 4-6: intermediate probability, </= 3: low probability

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Optimization of GDMT

• Continued Metoprolol XL 100 mg daily

• Started Entresto 24/26 mg BID optimized to 49/51

• Added back Spironolactone 12.5 mg -> optimized to 25 mg

• Renal function remained stable

• Repeat TTE after ~4 months optimization with LV recovery 50-55% (5.3 cm), RV mild to moderately reduced function (2.22 cm), trace TR, mild MR

• Increased Entresto to 97/103 mg BID

• Schedule patient for diagnostics

Outpatient LVAD Wean

• NYHA Class I symptoms, HR 90, BP 82 by Doppler

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• Weaned RPMs by 60 over 15-20 minutes to 1800 RPMs

• Remained asymptomatic, HR 91, BP 91/55

Of note, we did give 70 mg Lovenox for subtherapeuticINR 1.6 (goal > 2 for wean) before wean.

VO2 Max Treadmill StressTest(1800 RPMs)

• Performed using Balke protocol

• Asymptomatic during test

• Walked for 5:23, stopped due to leg discomfort and fatigue

• Achieved max HR 150, BP 155/67 (*pre HR 92, BP 94/69)

• VO2 max 15.7 ml/kg/min, 55% predicted

• RER 1.06, VE/VCO2 28 (81% predicted)

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Right Heart Catheterization(1800 RPMs)

• RA 12

• PA 42/22 with PA mean 29

• PCWP 21

• PA Sat 60.7%

• fCO/CI 2.89/1.61

• tCO/CI 3.87/2.15

• PVR 2.1-2.8

Transthoracic ECHO(1800 RPMs)

• LVEF remained 50-55%

• LVEDd 4.3 cm

• Technically difficult study so all valves not well visualized

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Transesophageal ECHO(1800 RPMs)

• LVEF again remains 50-55%

• RV normal cavity size with mild to moderately reduced function

• Moderate to severe degenerative MR with prolapse of A2 and A3 of anterior mitral leaflet

• Trace TR

*When LVAD speeds returned to baseline 2660 RPMs, the MR reduced back to mild to moderate

MitraClip to Explant

• Pre: PA 58/30 73%, PCWP 26, LA 20/20/16

• Turned LVAD speed down to 2200 RPMs prior to clip deployment

• 1 MitraClip implanted on A2/P2 mitral leaflet scallops with reduction in MR from severe to mild

• Post: PA 42/24 77%, PCWP 17, LA 18/18/16

The following day the patient underwent successful HVAD explant via L thoracotomy and was discharged on POD 6 (Metoprolol XL only)

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Post Explant TTE PODs 1 and 3

• LVEF 60-65%, LVEDd 4.3 cm

• Trace to mild MR

• RV normal cavity size with mildly reduced function

Serial ECHOs

• 1 month – LVEF 40-45%, mil/mod MR, RV moderately reduced function

• 4 months – LVEF 50-55%, mil/mod MR, RV mildly reduced function

• 6 months – LVEF 50-55%, mil/mod MR, RV mild to mod reduced function (3.6 cm)

• 12 months – LVEF 50-55%, mil/mod MR, RV moderately reduced function

GDMT currently and at last TTE: Metoprolol XL 50 mg daily, Entresto 49/51 mg BID, Spironolactone 25 mg daily AND NYHA Class I-II Symptoms

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Evaluating for Myocardial Recovery

• Calculate I-CARS score for every patient, consider for recovery if score >/+7

• GDMT (BB, ANRI/Ace/ARB, AA, Digoxin)

-suggested max doses

• Serial ECHOs at 1, 3, and 6 months, repeat at 9 and 12 months if show improvement in LVEF

• RAMP speed down – ECHO (baseline and low speed), RHC (both), VO2 max (at low speed), 6MWT (at low speed)

Low speeds for HMII 6000, HVAD 1800, HM3 3000

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Explantation Criteria

• ECHO

-LVEDd < 6 cm

-LVESd < 5 cm

-LVEF > 45%

• Hemodynamic Criteria

-PCWP < 15 mmHg

-CI > 2.2

• VO2 max

- > 16 ml/kg/min or > 50% predicted

Thank You

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References

• Antonides, Christian F.J., et al., Outcomes of patients after successful left ventricular assist device explantation: a EUROMACS study. ESC Heart Failure, 2020. 7: 1085-1094.

• Birks, Emma J., et al., Prospective Multicenter Study of Myocardial Recovery Using Left Ventricular Assist Devices (RESTAGE-HF [Remission from Stage D Heart Failure]). Circulation, 2020. 142: 2016-2028.

• Gyoten, T., et al., Cardiac recovery following left ventricular assist device therapy: experience of complete device explantation including ventricular patch plasty. European Journal of Cardio-Thoracic Surgery, 2021. 59: 855-862.

• Mulzer, J., et al., Myocardial function recovery interventional assessment and surgical pump removal. Ann Cardiothorac Surg, 2021. 10(3): 402-404.

• Vela, Maria M., et al., A detailed explantation assessment protocol for patients with left ventricular assist devices with myocardial recovery. Interactive CardioVascular and Thoracic Surgery, 2021. 32: 298-305.

• Wever-Pinzon, O., et al., Cardiac Recovery During Long-Term Left Ventricular Assist Device Support. J Am Coll Cardiol, 2016. 68(14): p. 1540-53.