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LVADs can benefit patients with restrictive cardiomyopathy
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Left ventricular assist devices may be a viable option for patients with end-stage restrictive cardiomyopathy.
Patients with restrictive cardiomyopathy have poor prognosis because of impaired ventricular filling, among other factors, according to a new study published in the Journal of Heart and Lung Transplantation. Researchers evaluated outcomes for patients with end-stage restrictive cardiomyopathy who received LVADs and aimed to determine which factors might play a role in improved survival.
The study included 28 consecutive patients with end-stage restrictive cardiomyopathy who received a continuous-flow LVAD (HeartMate II, Thoratec or HVAD, HeartWare) at Mayo Clinic from January 2008 to August 2013. The primary outcome was survival with LVAD support until death or transplantation. Mean follow-up was 448 days.
The mean hospitalization time was 29 days, and the most common complication was right ventricular failure, Sudhir S. Kushwaha, MD, medical director of cardiac transplantation and mechanical circulatory support at Mayo Clinic, and colleagues reported.
Short-term, in-hospital mortality was 14%. Of those who survived that period, 54% had no complications related to their LVAD during the study period. All 10 patients who received a heart transplant survived during the follow-up period, according to the findings.
Among those who did not have a heart transplant, the 1-year survival rate was 64%. Mean survival time was not significantly different between patients who had amyloidosis and those who did not (P = .94), Kushwaha and colleagues found.
Two factors were associated with improved survival rates: larger LV end-diastolic dimensions (RR = 0.94; P < .05) and larger LV end-systolic dimensions (RR = 0.95; P < .05). Conversely, LV end-diastolic diameter 46 mm or less was associated with increased risk for death after LVAD implantation (P < .01).
“We now know we can improve clinical outcomes for patients with end-stage restrictive cardiomyopathy by using [an LVAD], which has become a standard therapeutic device for treating [HF] in dilated and ischemic cardiomyopathy,” Kushwaha said in a press release. “This is promising news, because patients with [restrictive cardiomyopathy] have few therapeutic options and we continue to face donor shortages for transplant patients.” – by Erik Swain
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopFrank Smart, MD
It is helpful to know that this operation can be done in restrictive cardiomyopathy. It’s important, even though there is a small number of patients affected, because most people feel that it is limited in right ventricular performance, as restrictive myopathy is a systemic problem. The unfortunate side is that the survival rates at the 2- and 3-year marks were not what we have come to expect from LVADs alone. I don’t think it is ready yet for prime time as a destination therapy. That’s a lot of surgery for a small gain. Only 20% of the patients were still alive at 3 years. However, it is a very important step in the right direction to help us determine how to help this group of patients.
This could be a paradigm shift in the way we treat patients with restrictive cardiomyopathy. In the past, we have just given them supportive care, and that now has expanded to include the placement of an LVAD. We are a long way from a cost-effective cure, but there will be a substantial amount of shift in care for these individuals. This is one of those cases where desperate diseases deserve desperate measures. There really is nothing else that we can do for them.
These findings will surely prompt clinicians to consider LVAD implantation in these patients. There are a lot of questions that still need to be answered, such as how right ventricular function will play out. According to the study, the investigators were able to medically support people with right ventricular failure in the early postoperative period. That could be the biggest negative: If we were to go overboard, we would end up with a bunch of people on biventricular support, from which there is no good long-term outcome except transplant.
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