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Bridge to Removal: A Paradigm Shift for Left Ventricular Assist Device Therapy
Selzman and colleagues provide an outstanding overview of the state of the art of bridge to recovery, describing a paradigm shift that has been occurring. A consistent theme over the years is that recovery likelihood is enhanced in younger patients, those with non-ischemic cardiomyopathy, and those who have had HF for shorter durations. Although the INTERMACS database reflects that only about 1% of patients are successfully bridged to recovery, several studies have demonstrated that more patients may be recovered if a proactive approach is undertaken. Such an approach necessarily includes the early identification of potential candidates for removal, the modification of the surgical approach to facilitate later device removal, an active surveillance program, the institution of intensive adjuvant medical therapy, the adoption of standardized weaning protocols, and further exploration of less invasive techniques for removal. The authors effectively argue that only with a wholesale expansion of such a paradigm shift will more patients be successfully weaned. The devil--of course--lays in the details. The ongoing RESTAGE-HF trial will hopefully elucidate some of these details.