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• W28452983 abstract "Implanting a mechanical cardiac assist system as a bridge to transplantation or for long-term support is ultimately the only immediately available therapy for treating endstage cardiac diseases after conservative drug therapy has failed. The primary indications for implanting a cardiac support system are ischemic heart disease and idiopathic dilated cardiomyopathy (IDC). IDC is frequently associated with the presence of anti-β1adrenoceptor (A-β1-AAB) and other autoantibodies in the sera of patients directed against cardiac structures. This present study assessed whether changes in A-β1-AAB levels during mechanical cardiac support might be used as an indicator for cardiac recovery with the ultimate goal of weaning patients from the device instead of performing transplantation on them. Between April 1994 and May 1995, 17 patients with endstage non-ischemic IDC were implanted with univentricular cardiac assist systems (the wearable Novacor N100 system or TCI HeartMate) as a bridge to transplantation. All of the patients were male, in New York Heart Association (NYHA) class IV-D, had a cardiac index below 1.6 liters per minute per square meter of body-surface area (1 min−1 m−2), a left ventricular ejection fraction (LVEF) below 16%, and a left ventricular internal diameter in diastole (LVIDd) of more than 68 mm. Echocardiographic examinations were performed preoperatively and weekly after implantation. Likewise, the sera of these patients were examined for A-β1-AAB with a bioassay immediately before device implantation and once a week thereafter. The mean age of the patients was 49 ± 11 years (range: 32 to 67 years). Six patients died of various causes (3 due to bleeding, 1 due to multiorgan failure, and 2 because of technical reasons). The average duration of support was 160 ± 109 days (range: 37 to 475 days). Presently 4 patients continue to receive support. Three patients were transplanted after 75, 95 and 225 days of assisted circulation, respectively. The sera of all patients were considered positive for A-β1-AAB preoperatively with a value of 6.5 ± 0.8 laboratory units (LU) (range, 5.2 to 7.5 LU) and within the first 2 weeks postoperatively. During the course of circulatory support, the A-β1-AAB levels decreased in all of the patients and had completely disappeared 12 ± 5 weeks (range, 8 to 25 weeks) postoperatively. Parallel to this development echocardiographic examinations indicated an improvement in cardiac LVEF to an average of 31 ± 14% (range: 15 to 50%) and a decrease in LVIDd to mean values of 64 ± 10 mm (range: 25 to 81 mm). Four patients who exhibited improvement in cardiac function to near normal values were weaned from the device after 160, 243, 348 and 200 days of support, respectively. To reduce the risk of this new untested procedure, the devices were programmed to operate in an asynchronous drive mode for 3 weeks, which led to a significant increase in afterload of the left ventricle. Under these conditions neither a deterioration in cardiac function was observed through echocardiography nor an increase in A-β1-AAB through blood samples. Nevertheless, in 1 case it was decided to wean a patient due to thromboembolic complications and another due to a severe infection in the assist device pocket. Both decisions were additionally influenced by the unavailability of donor hearts. The device was explanted from a third patient as a planned procedure. As of March 31, 1996, these patients have been off the device for 389, 307, 299 and 185 days, respectively, with no increase in A-β1-AAB levels while exhibiting stable adequate cardiac function with a tendency towards further improvement Mechanical cardiac support in patients with IDC and A-β1-AAB simultaneously leads to a significant improvement in cardiac function and the disappearance of A-β1-AAB. Assuming that A-β1-AAB may cause cardiac dilatation and functional impairment, weaning from the device is possible as long as A-β1-AAB has disappeared and cardiac function improved. However, as the duration of cardiac stability is not predictable, it remains to be seen whether cardiac function has made a long-term recovery. Nevertheless, the results of this study indicate that this procedure may open a new concept in the treatment of endstage IDC. Implanting a mechanical cardiac assist device is often the only means available for supporting the hemodynamic condition in patients with endstage heart failure if a donor heart is not available. As of 1994 this method had been performed approximately 584 times worldwide for bridging to transplantation with an exponentially increasing trend (12, 20, 24, 30). The possibility of using temporary cardiac assist device support to give the heart an opportunity to recover has been considered for some time. Isolated cases involving patients with acute myocarditis or postcardiotomy have been reported (13, 26, 28, 30, 32). This idea was conceived after it was clinically observed that cardiac ejection fraction and diameter improved significantly in some patients supported with a cardiac assist device. It was therefore hypothesized that the macroscopically visible improvement in cardiac function must have a “microscopical” correlate which might show changes during mechanical cardiac support. The investigation was limited to patients who clinically exhibited (non-ischemic) IDC, since significant cardiac improvements were only observed in this cohort. There is evidence from both clinical and experimental studies that in a subset of patients an autoimmunological mechanism might be primarily or secondarily involved in the pathogenesis of IDC, by definition a disease of unknown origin nevertheless believed to be a sequela of viral myocarditis in many cases. Thus, cardioactive immunoglobulins circulating in patients with these diseases have been found to attach themselves to various structures of the myocardial cells, as indicated by immunofluorescence staining. Cardiac autoantigens identified in myocarditis and IDC include the mitochondrial ADP/ATP carrier, the branched chain keto acid dehydrogenase, the cardiac myosin heavy chain, laminin, and the β1-adrenoceptor (3, 35, 43, 46), Autoantibodies directed against this receptor have been previously observed in the serum of patients with Chagas’ heart disease, whose clinical manifestations resemble those of IDC (1, 3, 4, 8, 10, 18, 19, 21, 22, 34, 35, 36, 39, 41, 43, 46). Using neonatal rat heart myocytes beating spontaneously in culture as a sensitive adrenergic effector system, as indicated by their chronotropic response to adrenoceptor stimulation, it was possible to show that the serum of patients with myocarditis and IDC contained autoantibodies of the IgG isotype capable of eliciting increases in the beating rate which could be maintained unabated for days. As a rule such antibodies were not observed in healthy control subjects or in patients with chronic ischemic heart disease and normal cardiac function and size or acute myocardial infarction (44, 45) (Wallukat et al., 1991a, 1991b). The possibility was considered that autoantibodies with chronotropic activity in the anti-β1-receptor may play a role in the harmful chronic adrenergic drive to which the hearts of patients with IDC are believed to be exposed (5, 9, 17, 40). In this present study the course of A-β1-AABs and functional cardiac parameters in patients with IDC who were implanted with mechanical left ventricular assist devices with the primary intention of bridging to transplantation were analyzed. The original goal of this present study was to develop a new therapeutic concept for weaning such patients from mechanically assisted circulation once they exhibited an improvement in cardiac function. This concept is comparable to that of the ESETCID Trial (European Study on Epidemiology and Therapy of Cardiomyopathy and Inflammatory Disease) initiated with the intention of treating patients with dilated cardiomyopathy or myocarditis according to the etiology of their diseases. The aforementioned goal of this study, however, was abandoned after it was observed that the implantation of an assist device alone led to changes in the immunological status of these patients. The following text reports success achieved in weaning patients from assist devices and describes the decision process for ex-planting the pumps. In 2 cases the decision for device explantation was precipitated due to special clinical conditions (infection and thromboembolism) which represented a significant threat to the patients." @default.
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• W28452983 title "Weaning from mechanical support after complete recovery in patients with idiopathic dilated cardiomyopathy" @default.
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