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. 2014 Apr;33(4):372-81.
doi: 10.1016/j.healun.2014.01.866. Epub 2014 Jan 27.

Assessment of myocardial viability and left ventricular function in patients supported by a left ventricular assist device

Deepak K Gupta  1 , Hicham Skali  1 , Jose Rivero  1 , Patricia Campbell  2 , Leslie Griffin  1 , Colleen Smith  1 , Courtney Foster  3 , Brian Claggett  1 , Robert J Glynn  4 , Gregory Couper  1 , Michael M Givertz  1 , Mandeep R Mehra  1 , Marcelo Di Carli  5 , Scott D Solomon  1 , Marc A Pfeffer  6
Affiliations

Assessment of myocardial viability and left ventricular function in patients supported by a left ventricular assist device

Deepak K Gupta et al. J Heart Lung Transplant. 2014 Apr.

Abstract

Background: Chronically supported left ventricular assist device (LVAD) patients may be candidates for novel therapies aimed at promoting reverse remodeling and myocardial recovery. However, the effect of hemodynamic unloading with a LVAD on myocardial viability and LV function in chronically supported LVAD patients has not been fully characterized. We aimed to develop a non-invasive imaging protocol to serially quantify native cardiac structure, function, and myocardial viability while at reduced LVAD support.

Methods: Clinically stable (n = 18) ambulatory patients (83% men, median age, 61 years) supported by a HeartMate II (Thoratec, Pleasanton, CA) LVAD (median durations of heart failure 4.6 years and LVAD support 7 months) were evaluated by echocardiography and technetium-99m ((99m)Tc)-sestamibi single photon emission computed tomography (SPECT) imaging at baseline and after an interval of 2 to 3 months. Echocardiographic measures of LV size and function, including speckle tracking-derived circumferential strain, were compared between ambulatory and reduced LVAD support at baseline and between baseline and follow-up at reduced LVAD support. The extent of myocardial viability by SPECT was compared between baseline and follow-up at reduced LVAD support.

Results: With reduction in LVAD speeds (6,600 rpm; interquartile range: 6,200, 7,400 rpm), LV size increased, LV systolic function remained stable, and filling pressures nominally worsened. After a median 2.1 months, cardiac structure, function, and the extent of viable myocardium, globally and regionally, was unchanged on repeat imaging while at reduced LVAD speed.

Conclusions: In clinically stable chronically supported LVAD patients, intrinsic cardiac structure, function, and myocardial viability did not significantly change over the pre-specified time frame. Echocardiographic circumferential strain and (99m)Tc-sestamibi SPECT myocardial viability imaging may provide useful non-invasive end points for the assessment of cardiac structure and function, particularly for phase II studies of novel therapies aimed at promoting reverse remodeling and myocardial recovery in LVAD patients.

Keywords: hemodynamic unloading; left ventricular assist device; reverse remodeling; single photon emission computed tomography; speckle tracking echocardiography.

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Figures

Figure 1
Figure 1
Consort diagram of LVAD imaging study.
Figure 2
Figure 2
A. Left ventricular systolic function was assessed with global circumferential strain (CS) from speckle tracking echocardiography at the mid ventricular level at the papillary muscles. B. At reduced LVAD support, LV systolic function (Global CS) is stable from baseline to follow up in chronically supported LVAD patients (each line represents a patient).
Figure 3
Figure 3
A. At reduced LVAD support, global left ventricular viability was assessed by 99mTc Sestamibi SPECT imaging at a threshold of 55% of peak normalized counts, after exclusion of segments containing the LVAD cannula (gray zones). B. At reduced LVAD support, the extent of global LV viability was stable from baseline to follow up in chronically supported LVAD patients (each line represents a patient).
Figure 4
Figure 4
A. At reduced LVAD support, the extent of regional LV viability was assessed by averaging peak normalized counts from 99mTc Sestamibi SPECT imaging in the target zone, defined as ≥ 2 contiguous segments with ≤ 55% of peak normalized counts within the same coronary distribution, after exclusion of segments containing the LVAD cannula. In this example of a patient with a history of a right coronary artery (RCA) STEMI, 4 segments (red) in the RCA territory comprised the target zone (average peak normalized counts = 35.3) B. At reduced LVAD support, the extent of regional LV viability in the target zones was stable from baseline to follow up in chronically supported LVAD patients (each line represents a patient).
Figure 5
Figure 5
The relationship between left ventricular viability and systolic function assessed by circumferential strain in chronically supported LVAD patients. A. The 6 mid LV segments were co-registered between SPECT (left) and echocardiographic (right) imaging in 15 patients. Each segment was categorized as viable (green) or non-viable (red) based upon >55% or ≤55% of peak normalized counts from 99mTc-Sestamibi SPECT imaging, respectively. Circumferential strain from speckle tracking echo was averaged in viable and non-viable segments. B. At reduced LVAD support, circumferential strain was compared between non-viable and viable segments over time and within studies (Baseline: Non viable vs viable p = 0.022; Follow Up: Non viable vs viable p = 0.017).
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