HFSA 2021: Defining and Achieving Heart Recovery

Manreet Kanwar, MD discusses heart recovery, exploring how we define it and how we achieve it. Dr. Kanwar is associate professor of medicine at Temple University and the director of mechanical circulatory support and cardiac transplantation program and advanced heart failure cardiology at Allegheny General Hospital in Pittsburgh, Pennsylvania. She gave this presentation at the 2021 Heart Failure Society of America (HFSA) scientific meeting.

Dr. Kanwar emphasizes, “Every patient should be assessed for the likelihood of recovery” rather than assuming that some patients—such as those in cardiogenic shock or those with durable left ventricular assist devices (LVADs)—may not recover and require cardiac transplantation.

She shares a poll with the HFSA audience, which she had initially presented to an audience of mostly cardiac surgeons. It asks about treatment options in the case of a 21-year-old woman with new onset viral cardiomyopathy who presented in acute SCAI stage C cardiogenic shock and was unable to be weaned from temporary mechanical circulatory support. The poll questions pertain to treatment options—which at the time were primarily durable LVADs or heart transplantation—and pertain to the likelihood of heart recovery. When she initially conducted the survey, only 2 of about 70 people chose the option of treating the patient with a durable LVAD as bridge-to-recovery, which is how the patient was ultimately, and successfully managed. “This was a 21-year-old female,” Dr. Kanwar explains. “Had we transplanted her… if you look at the mean survival of these patients, we would have probably added a meaningful 12, 15, who knows, maybe even 20 years to her life. And then what?”

After setting this foundation with the case study and poll, Dr. Kanwar defines and explores some terminology. She explains that heart failure physicians attempt to achieve “reverse remodeling,” which she defines as medical and device therapies that lead to decreased LV volume and mass and restore a more normal elliptical shape to the ventricle. Reverse remodeling may achieve either “myocardial recovery” with a clinical course that is free from future HF events, or “myocardial remission”, which is remodeling that is insufficient to prevent the recurrence of HF in the face of normal and/or perturbed hemodynamic loading conditions.

Dr. Kanwar explains the importance of looking for myocardial recovery after LVAD implantation. She defines bridge to recovery as “an intent.” “It is how you would meaningfully and deliberately have a program-based approach where you would take each and every patient—they could be on a temporary device or they could be on a durable device—and you optimize their VAD, again, be it temporary or durable, to make sure that the LV is adequately unloaded… and we place them on goal-directed medical therapy (GDMT). So, you intend, you design for them to recover.”

Dr. Kanwar explores which patients are most likely to recover, such as the 21-year-old, non-ischemic, shorter duration heart failure patient presenting in an acute scenario from her case study poll. She discusses unloading and the importance of ensuring that the selected device matches the patient’s needs. She emphasizes the clear chances of recovery seen in the RESTAGE-HF trial, and briefly discusses her “secret sauce” for care of these patients at Allegheny General Hospital.

“Anticipate myocardial recovery,” she concludes. “It is not as rare as we think it is… Deliberately promote myocardial recovery… because jumping to cardiac transplant directly is sometimes, again, very, very tempting, but not necessarily the right thing for that patient. So, I think it is time we rebrand our heart failure story to heart recovery.”