Ventricular function recovery on LVAD For idiopathic or ischemic CM P. Leprince, CT Surgery Institut of cardiology Pitié-Salpétrière Group Paris, France

Intermacs 1.4%

Intermacs 0.8% 0.9% 0.4% 1% 16% 0.3%

Hetzer R

Hetzer R

Hetzer R

Circulation. 2008;118[suppl 1]:S94–S105. Hetzer R

* 30<LVEF<44% at 55<LVEDD<66mm before VAD removal Hetzer R

15 patients The patients underwent implantation of left ventricular assist devices and were treated with lisinopril, carvedilol, spironolactone, and losartan to enhance reverse remodeling. Once regression of left ventricular enlargement had been achieved, the β2-adrenergic–receptor agonist clenbuterol was administered to prevent myocardial atrophy.

11 patients explanted, 1 death

Conclusions LVAD removal should be considered as contraindicated if off-pump LVEF does not exceed 40%. Patients with a history of HF of 5 years should be monitored very carefully after weaning Neither the LVIDd nor the LVEF measured before LVAD implantation are predictive for potential myocardial improvement during mechanical unloading.

Weaning rate: 8.8% Multivariate analysis: risk factor for sustained recovery Age: OR 1.036 Pulsatile: OR 2.719 (19.4% vs 2.46%)

14 BTR, 29 BTT, 29 Tx J Heart Lung Transplant 2008;27:165–72 SF-36: Physical, mental, Global

HMII and Myocardial recovery in ischemic CM P. Leprince, Institut de cardiologie Chirurgie Cardiovasculaire Groupe Hospitalier Pitié-Salpétrière Paris pascal.leprince@psl.aphp.fr

Medical History 51 years old female Smoker Regular physical activity March 14th: Fast run to get the bus Pain, Collapsed, spontaneous quick recovery March 15th: Family practitioner: normal exam, normal EKG March 16 and 17th: Dyspnea, fatigue

March 18: Pain recurrence, collapse Emergency room BP: 95/50 Persisting pain Heart rate : 110 TTE: extented akinesia (anterior and lateral wall, apex, septum). EF: < 25%  Dobutamine

After PTCA Dobutamine 10 mic IAPB BP 90 Pic troponin: 42 Stable biologie Clinical signs of poor peripheral perfusion after few hours ECMO

No recovery after 10 days

To test for potential recovery To buy time before transplantation HMII Implantation instead of high emergency list cardiac transplantation To test for potential recovery To buy time before transplantation

After implantation Good general status recovery Discharged directly to home after 20 days Echocardiography: Good LV unloading No aortic valve opening Myocardial contraction slightly better

Follow up No complication Good quality of life New Echocardiography in June

Vacation time 8000 rpm

Explantation: September

Follow-up

> 5 years Doing well on ACE inhinbitor and beta bloquers Normal life Back to physical activies Disappearance of apical clot Isotopic EF: 60%

5 ischemic patients /55 HMII patients 3 males, 2 females Age: 39 to 54 All with cardiogenic shock related to AMI ECMO + IABP + inotropes 6 to 10 days EF at implantation: 7 to 25% B-, ACE Inhib, Aldactone Weaning process started at 4 to 14 months Weaned at 7 to 21 months (EF 25 to 55%) 1 death related to septic shock

Conclusion Recovery does exist (5 to 10%) Every patient should be treated and screened for it Young age and short duration of heart failure are favorable factors for sustained recovery Role of pulsatility? Another advocacy for early implantation