Reversal of End–Stage Heart Failure—Mechanical and Pharmacologic Interplay

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Abstract

Background.

In patients with severe heart failure (HF), prolonged unloading of the myocardium with the use of a left ventricular (LV) assist device (LVAD) has been reported to lead to myocardial recovery in small numbers of patients for varying periods of time. Increasing the frequency and durability of myocardial recovery could reduce or postpone the need for subsequent heart transplantation.

Methods.

This study enrolled 15 patients with severe HF due to nonischemic cardiomyopathy and with no histologic evidence of active myocarditis. All had markedly reduced cardiac output and were receiving inotropes. The patients underwent implantation of LVADs and were treated with lisinopril, carvedilol, spironolactone, and losartan to enhance reverse remodeling. Once regression of LV enlargement had been achieved, the β2-adrenergic receptor agonist clenbuterol was administered to prevent myocardial atrophy.

Results.

Eleven of the 15 patients had sufficient myocardial recovery to undergo explantation of the LVAD a mean ± SD 320±186 days after implantation of the device. One patient died of intractable arrhythmias 24 hours after explantation; another died of carcinoma of the lung 27 months after explantation. The cumulative rate of freedom from recurrent HF among the surviving patients was 100% and 88.9% one and 4 years after explantation, respectively. The quality of life as assessed by the Minnesota Living With Heart Failure Questionnaire score at 3 years was nearly normal. Fifty-nine months after explantation, the mean LV ejection fraction was 64%±12%, the mean LV end-diastolic diameter was 59.4±12.1 mm, the mean LV end-systolic diameter was 42.5±13.2 mm, and the mean maximal oxygen uptake with exercise was 26.3±6.0 mL/kg per minute.

Conclusions.

In this single-center study, the authors found that sustained reversal of severe HF secondary to nonischemic cardiomyopathy could be achieved in selected patients with the use of an LVAD and a specific pharmacologic regimen.

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