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Although significant cardiac reverse remodeling is a prerequisite for a left ventricular (LV) assist device (LVAD) patient to be considered for device weaning, multiple factors including patient goals, physician comfort, and center experience, weigh in on this complex decision. Existing predictive models defining recovery as device withdrawal, entail the above-mentioned confounders, and may under detect patients that could benefit from a targeted bridge to recovery strategy. We sought to derive and validate a predictive tool to identify patients prone to reverse remodel, independent of the complex decision to remove a durable, surgically deployed device. Heart failure patients (N=782) requiring LVAD were enrolled at one (n=537) and five US programs (n=245). Baseline characteristics were recorded. The primary outcome was responder incidence, defined as follow-up LV ejection fraction ≥40% and LV end-diastolic diameter ≤6 cm within one year on LVAD support. Bootstrap imputation and lasso variable selection techniques were used to derive a predictive model which was then validated using our multicenter dataset. A predictive calculator was developed, and patients were classified into groups with varying potential for reverse remodeling. Patients were predominantly white (84%), male (82%), aged 56±1 years. Overall, 14.8% patients were identified as responders. Nine preoperative variables associated with reverse remodeling were included in the multivariate model achieving an optimism corrected C-statistic of 0.77 (95% CI: 0.71-0.82) (Figure). The UCAR calculator is a machine learning-based multicenter and validated risk tool, implementing routine clinical data, that effectively stratifies patients into groups with varying potential for reverse remodeling. This tool can be useful in selecting patients to implement diagnostic and therapeutic protocols that can promote reverse remodeling and myocardial recovery. [ABSTRACT FROM AUTHOR]

Although significant reverse cardiac remodeling is required for an LVAD-supported patient to be considered for device weaning, multiple factors including patient willingness, physician expertise, and center experience influence this complex decision. Existing predictive models defining cardiac recovery as device removal might underestimate reverse remodeling rates and lack accuracy in identifying patients prone to improve cardiac structure and function. We sought to develop a predictive tool to identify patients with such potential, independent of the decision to deactivate a durable, surgically deployed device. Chronic HF patients (N=703) requiring continuous-flow LVADs were evaluated. After excluding patients with acute HF and/or <3 months post-LVAD follow up, 3 US programs contributed 390 patients (derivation cohort), while 5 US programs formed the validation cohort (n=245). We defined responders as patients with an LVEF ≥40% and LVEDD ≤6.0 cm within a year on LVAD support. Multivariable logistic regression on the derivation set yielded a predictive model, which was externally tested; a predictive score was developed. Overall, 18.5% of the patients were responders. Compared to the validation, patients in the derivation cohort were more likely white (83 vs 69%; p<0.001), with ischemic HF (42 vs 33%; p=0.04), and longer HF duration (88 vs 66 months; p<0.001). Multivariable predictors of responders and the derived scoring system are shown in the Figure (c-statistic 0.74 [95% CI: 0.66-0.83] and 0.71 [95% CI: 0.59-0.77] in the derivation and validation set). We propose a novel score to predict significant cardiac improvement on LVAD support achieving good discriminative performance in distinct, heterogeneous, contemporary cohorts. This tool can be useful in selecting patients to implement diagnostic and therapeutic protocols to promote reverse remodeling and myocardial recovery. [ABSTRACT FROM AUTHOR]

LVAD therapy has been primarily studied in patients with elevated pulmonary capillary wedge pressure (PCW) and low cardiac index (CI), "cold and wet". In daily practice, LVADs are often also offered to patients with low PCW and low CI, "cold and dry". The efficacy of LVAD therapy in this population is not well studied. Patients implanted with LVAD with a baseline CI <2.0 Lpm were categorized as "wet" (PCW>18mmHg) or "dry" (PCW<18mmHg). These values were derived from serial pre-LVAD right heart catheterization studies in order to reflect a sustainable hemodynamic profile. Variables of interest and 3-year survival were compared between groups. Independent predictors of mortality were identified using multivariate Cox regression analysis. Serial invasive hemodynamics data was available for 92 pts (cold-dry group, n=34 and cold-wet group, n=58) (Table). Diuretic and vasodilator use pre-LVAD was comparable in both groups. Cold-dry patients had no change in CVP or PCW with a smaller increase in CI after LVAD. Adjusted 3-year mortality was higher for cold-dry patients (Figure). Age (HR=1.09, 95%CI 1.02-1.2; p=006) and cold-dry profile (HR=5.4, 95%CI 1.4-21; p=0.016) were identified as independent predictors of mortality. "Cold and dry" patients with advanced heart failure may not derive equal benefit from LVAD therapy as those who are "cold and wet". This observation warrants further investigation. [ABSTRACT FROM AUTHOR]

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a serious complication with poor prognosis. Improved selection of patients with greater risk of developing the condition is crucial, considering the growing need for destination therapy patients. However, predicting RVF remains a vexing clinical problem. From 2008 to 2019, 478 consecutive chronic heart failure (HF) patients supported with continuous-flow LVADs were prospectively evaluated. RVF was defined by the need for intravenous inotropes for >14 days and/or right ventricular assist device implantation. Data was analyzed based on the presence or absence of RVF in the early post-operative period and their baseline clinical, hemodynamic, imaging and laboratory data were compared. Multivariable logistic regression was used to develop a clinical model for RVF prediction. Overall, 77 (16.1%) patients developed RVF. Univariate analysis showed that the RVF was associated with higher acuity disease before LVAD implantation reflected by low INTERMACS profile, high vasoactive medication requirement, presence of IABP support, hyponatremia, thrombocytopenia, low serum albumin, and renal dysfunction. Additionally, RVF was associated with increased heart rate, right atrial (RA) and right atrial to wedge pressure (RA/PCWP) ratio, along with decreased systolic pulmonary artery pressure (PAP), right ventricular stroke work index (RVSWi) and pulmonary artery pulsatility index (PAPi), at baseline. Interestingly, patients who developed RVF had decreased left ventricular end-diastolic diameter at baseline, when compared to the no RVF group. The multivariate model (AUC=0.77; p<0.0001) predicted RVF using 7 clinical parameters: 1) Remote history of systemic hypertension, 2) Preoperative need for IABP, 3) Systolic PAP <60 mmHg, 4) RA/PCWP ≥0.66, 5) PAPi <1.44, 6) Na <135 mEq/L, & 7) PLT <100 × 103/microL Our model seems capable of distinguishing patients prone to develop RVF post-LVAD implantation. The identified pre-LVAD predictors include markers of globally advanced HF syndrome and higher acuity as well as markers specific to severity of RVF. [ABSTRACT FROM AUTHOR]

Purpose Predicting cardiac recovery (CR) in advanced heart failure (HF) patients before left ventricular assist device (LVAD) implantation remains challenging. This study sought to investigate whether CR after LVAD unloading can be predicted by cardiac functional and structural parameters together with clinical characteristics. Methods From 2008 to 2016, consecutive advanced chronic HF patients (N=347) supported with durable continuous-flow LVADs were prospectively evaluated. Patients with acute HF etiologies or without adequate post-LVAD follow up (<3 months) were excluded. A great variety of clinical characteristics were evaluated in the remaining 285 subjects. LVAD patients were phenotyped while on support, as CR Responders or Non Responders, based on published predefined echocardiographic criteria. Multivariable logistic regression was used to form the model and the Utah Cardiac Recovery (UCAR) score was created from the regression beta coefficients of the final model. Results CR occurred in 13.7% of patients. Univariate analysis showed that responders were more likely to be young, female, non-ischemic cardiomyopathy, with shorter HF symptoms duration and no prior heart surgery. They had lower blood urea nitrogen and were less likely to be on temporary mechanical support before LVAD. The multivariable UCAR model (AUC=0.755; p<0.001) predicted CR using 3 clinical parameters - Table. Conclusion Univariate and multivariable predictors of CR include both modifiable and non-modifiable patient characteristics that are known prior to LVAD implantation. The UCAR score can serve as a practical tool for targeted patient selection to implement protocols that facilitate CR in the advanced HF patient subpopulation that is most likely to respond. [ABSTRACT FROM AUTHOR]

Recent studies have shown enhanced survival and reduced morbidity with centrifugal (HeartMate 3-HM3) left ventricular assist device (LVAD) compared with axial-flow (HeartMate II-HMII) LVAD. However, differences in LVAD-induced left ventricular (LV) reverse remodeling between the two devices remain uninvestigated. The aim of our study was to compare the LV structural and functional changes between these two types of mechanical unloading. Echocardiographic parameters of LV structure and function were obtained pre-implant and at 1, 3, 6, and 12 month of LVAD support. Statistical comparison of quantitative data was performed using 2-tailed Wilcoxon signed-rank test for paired samples and categorical data were compared using Fisher's exact test. A total of 32 consecutive patients (median age 62.5 [IQR 52-68] years, 15.6% female) received axial-flow LVAD (HMII) and 31 consecutive patients (median age 58 [IQR 47-71] years, 16.1% female) received centrifugal LVADs (HM3). There were no significant differences in the baseline characteristics between the study groups. Following LVAD support there were no differences in the LV ejection fraction or LV mass index between the two types of mechanical unloading across all time points (figure 1A and 1B). In centrifugal LVAD patients, LV end diastolic volume index was lower at 1 and 3 months and LV end systolic volume index was lower at 1 month. No differences were identified after 3 months of mechanical unloading (figure 1C and 1D). Both centrifugal and axial-flow LVADs resulted in improved LV function and structure. Although LV volumes were found to be lower at 1 and 3 months in centrifugal pump patients, long-term (> 3month) mechanical unloading seem to exert similar effects on LV structural and functional parameters. [ABSTRACT FROM AUTHOR]