Left Atrial Reverse Remodeling In Patients Supported With Durable Left Ventricular Assist Devices And Clinical Implications

Abstract

Introduction

The left atrium (LA) maintains a dynamic interaction with the left ventricle (LV). LA forward and reverse remodeling affect prognosis in patients with chronic heart failure (HF).

Hypothesis

We sought to examine LA reverse remodeling in patients supported with LV assist devices (LVADs) and investigate a potential impact on clinical outcomes.

Methods

Consecutive advanced HF patients receiving durable, continuous-flow LVAD were prospectively evaluated (n=263). After excluding patients with unavailable echocardiographic data, 241 patients were studied. Echocardiographic assessment was performed pre- and serially post-LVAD implantation. We assessed LA and LV structure and function and their association, and the impact of LA reverse remodeling on all-cause mortality, LVAD-related adverse events, and atrial fibrillation (AF).

Results

Most patients were male, white, with a mean age of 56±15 years. Forty-four percent had underlying ischemic cardiomyopathy, 65% were INTERMACS profile 1-3, with a mean LV ejection fraction of 19±7%, and end-diastolic diameter of 6.7±1.1 cm, pre-LVAD. LA structure and function improved by 1-month on LVAD support and remained improved by 12 months, as evidenced by LA volumes, emptying volumes, and emptying fractions in patients without AF (Figure 1). A similar pattern was observed in patients with AF. LA changes were shown to be associated with LV structural and functional changes. The magnitude of LA reverse remodeling was associated with all-cause mortality, but not cerebrovascular accident/transient ischemic attack, or LVAD thrombosis rates by 12 months on LVAD support. Of 46 patients with AF pre-LVAD, 28 (61%) converted to sinus rhythm, and 18 (39%) remained on AF during serial echocardiographic assessment.

Conclusion

LA structure and function improved early during LVAD support, showed stability of improvement during follow-up, and were associated with simultaneous LV changes. Implications on all-cause mortality and AF may inform the care of patients who are considered for advanced HF therapies, as well as the broader population of patients with HF and concomitant AF undergoing pharmacological unloading.