Recurrent remodeling after ventricular assistance: Is long-term myocardialrecovery attainable?

Background. Long-term left ventricular assist devices (LVAD) have been used both as a bridge to heart transplantation and to recovery of native myocar dial function. Despite much evidence for reversal of some of the structural and functional changes present in the failing heart during LVAD support, c linical evidence for sustained myocardial recovery is scant. We describe 2 patients in whom myocardial recovery during LVAD support led to device expl anation only to have heart failure recur. This necessitated a second LVAD i mplantation, a process that we have termed recurrent remodeling. Methods. The medical records of 2 patients with cardiomyopathy supported wi th HeartMate LVADs (Thermo Cardiosystems, Inc, Woburn, MA) were retrospecti vely reviewed. Results. One patient was supported with an LVAD for 2 months, at which time the LVAD was explanted. progressive deterioration of cardiac function foll owed, requiring a second LVAD 19 months after LVAD explanation. After 2 mon ths of further LVAD support, a second episode of apparent myocardial recove ry was observed during a period of device malfunction. The other patient wa s supported with an LVAD for 12 months, at which time the LVAD was explante d. The patient experienced progressive hemodynamic deterioration and requir ed a second LVAD 6 months after LVAD explantation. Heart transplantations o f both patients were successful. Conclusions. Our understanding of myocardial recovery in the setting of hem odynamic unloading with LVAD support has not yet progressed to the point wh ere we are able to accurately predict successful long-term LVAD explantatio n. The evolution of reliable predictors of sustainable myocardial recovery will help to avoid further cases of recurrent remodeling requiring repeat L VAD implantation. (C) 2000 by The Society of Thoracic Surgeons.