Dr Bobbi Chapman from Abiomed welcomed everyone to this interactive panel discussion and introduced the panellists, starting with Dr Jane Wilcox, Chief of the Section of Heart Failure Treatment and Recovery at Northwestern University Feinberg School of Medicine in Chicago, US, and principal investigator of the Impella BTR™ Early Feasibility Study (BTR EFS), and then Dr Manreet Kanwar, Section Head of the AGH McGinnis Cardiovascular Institute at Allegheny General Hospital in Pittsburgh, US, and founding member of the Cardiogenic Shock Working Group, and Dr Bart Meyns, Professor and Chief of Cardiac Surgery at the University Hospital Leuven in Leuven, Belgium.
Dr Chapman opened the discussion by inviting each panellist to describe their approach to heart recovery in their own clinical practice and set out the circumstances in which they choose to use unloading as part of their strategy to achieve recovery.
Dr Wilcox acknowledged that the notion of recovery is very broad and the identification of ‘recoverable’ patients does not yet have clear-cut guidelines. When patients with chronic worsening heart failure present, she first performs right heart catheterisation to monitor the pulmonary capillary wedge pressure (PCWP) and cardiac index. When patients with high PCWP and low cardiac index are identified, the first discussion centres around finding ways to optimise the patient with other means prior to considering advanced therapy. In particular, when Dr Wilcox sees a young patient with relatively preserved global longitudinal strain and no prior exposure to angiotensin receptor–neprilysin inhibitor (ARNI) or high-dose beta-blockers, she sees an opportunity to attempt native heart recovery using temporary unloading alongside guideline-directed medical therapy (GDMT). For patients who have not yet been treated with ARNI, she would strongly consider temporary unloading and ARNI.
Dr Kanwar explained that her aim is always to look for a path to recovery, and that drives her strategy. Active unloading in cardiogenic shock (CS) is well supported. In addition, Dr Kanwar will try to identify any reversible underlying trigger of heart failure that can be treated.
Dr Meyns aims for recovery in all his patients. In his clinical practice, in appropriate patient populations, he considers a 6-month wait period with GDMT and reassesses the patient for signs of native heart recovery prior to heart transplant. He uses the axillary Impella support in his patients as a part of this approach. His goal is always recovery.
Continuing from the panellists’ overriding pursuit of recovery for their patients, the moderator asked the panellists to outline what they would look for in an ideal recovery device. What features should it have to better wean patients, improve support and achieve recovery in more patients?
Dr Kanwar would like to see assistive technologies that can provide more information about the degree of reverse remodelling, including the response to active unloading and change in the degree of myocardial fibrosis. For her, the duration of support of any temporary mechanical circulatory support (MCS) device is key; 14 days, for example, may be insufficient time for recovery. Ideally, she would be looking for a device with a longer duration time and one that is associated with fewer adverse events.
Dr Wilcox answered that the most important feature in a device for her is the stability of the platform. She generally uses the Impella 5.5 because it fulfils this criterion. The Impella 5.5 also offers the additional benefit of being inserted through axillary access, which allows for patient ambulation. Dr Wilcox noted the importance of monitoring native heart function during the period of support, along with monitoring of the patient’s trajectory. The goal is to get the patient out of CS and onto GDMT.
Dr Meyns would like to see a device that can be placed in a minimally invasive fashion, that enables a patient to be discharged home and that offers a support duration spectrum of 6–12 months. For him, the patient’s ability to tolerate MCS weaning is important in guiding decisions. Dr Meyns finds the Impella pumps particularly helpful in this respect because they can be run down to no flow or close to no flow to enable a trial weaning prior to explanting the device. In addition, temporary MCS preserves the apex muscle.
Dr Kanwar agreed that it typically takes 6–12 months to achieve recovery of over 40%. At this point in time, although complete normalisation of left ventricular function is rarely achieved, the hearts have recovered to the point that GDMT can be tolerated and the native ejection fraction of >30% allows for the patient to avoid transplant.
Given that financial incentives to recover patients are lacking, the moderator next asked the panellists how they overcome this barrier within their own clinical teams and the hospital.
Dr Kanwar replied that in her clinical practice, with the active implementation of MCS devices, she is seeing the lowest rates of heart transplant and, conversely, high rates of recovery in CS patients. She believes these success rates are down to careful patient selection. Although she acknowledges that her institution is paying for this success financially, she believes patient outcomes should take priority.
Dr Chapman thanked the panellists for their contributions to a highly productive discussion and closed by recapping that further work is required to improve the means of identifying which patients are recoverable; best practices should be developed to help others gain the maximal advantage with Impella technology in a variety of clinical settings, and there is a need to develop smarter pumps that are dischargeable. 