Perspective:

LVADs are implanted as either a bridge to transplant or destination therapy in American College of Cardiology/American Heart Association (ACC/AHA) Stage D (i.e., advanced) HF patients who are refractory to or intolerant of guideline-directed medical therapy. The hemodynamic unloading provided by this durable mechanical circulatory support may result in reverse structural remodeling to such a degree that, in certain patients with sustained improved myocardial function, pump removal can safely and durably occur. The literature suggests that LVAD explantation occurs rather infrequently (1-2% per the INTERMACS registry). Thus, the authors are to be commended for the RESTAGE-HF study, which reports the primary outcomes of a multicenter, prospective study using a uniform protocol of LVAD pump speed optimization combined with an aggressive drug regimen and regular testing of underlying myocardial function.

Of note, the study protocol required that patients agree to not undergo heart transplantation for a minimum of 4.5 months after LVAD implantation. Interestingly, a multivariate analysis showed that none of the “traditional” clinical risk factors predicted recovery, including age, duration of HF, presence of cardiac resynchronization therapy, or an underlying diagnosis of familial, postpartum, or chemotherapy-induced cardiomyopathy. A univariate analysis did show that lower preoperative creatinine was associated with a higher subsequent chance of recovery, which may be explained by tolerance of higher doses of renin-angiotensin-aldosterone system (RAAS) inhibitors. The authors appropriately acknowledge several limitations, including the young age of patients studied, along with the relatively small number of patients and the lack of a control arm, thereby limiting generalizability of the findings. These data are encouraging and hypothesis generating and may compel several centers to consider LVAD explantation in more chronic HF patients with myocardial recovery.