Calculation of the ALMA Risk of Right Ventricular Failure After Left Ventricular Assist Device Implantation

Abstract

Right ventricular failure after continuous-flow left ventricular assist device (LVAD) implantation is still an unsolved issue and remains a life-threatening event for patients. We undertook this study to determine predictors of the patients who are candidates for isolated LVAD therapy as opposed to biventricular support (BVAD). We reviewed demographic, echocardiographic, hemodynamic, and laboratory variables for 258 patients who underwent both isolated LVAD implantation and unplanned BVAD because of early right ventricular failure after LVAD insertion, between 2006 and 2017 (LVAD = 170 and BVAD = 88). The final study patients were randomly divided into derivation (79.8%, n = 206) and validation (20.1%, n = 52) cohorts. Fifty-seven preoperative risk factors were compared between patients who were successfully managed with an LVAD and those who required a BVAD. Nineteen variables demonstrated statistical significance on univariable analysis. Multivariable logistic regression analysis identified destination therapy (odds ratio [OR] 2.0 [1.7-3.9], p = 0.003), a pulmonary artery pulsatility index <2 (OR 3.3 [1.7-6.1], p = 0.001), a right ventricle/left ventricle end-diastolic diameter ratio >0.75 (OR 2.7 [1.5-5.5], p = 0.001), an right ventricle stroke work index <300 mm Hg/ml/m (OR 4.3 [2.5-7.3], p < 0.001), and a United Network for Organ Sharing modified Model for End-Stage Liver Disease Excluding INR score >17 (OR 3.5 [1.9-6.9], p < 0.001) as the major predictors of the need for BVAD. Using these data, we propose a simple risk calculator to determine the suitability of patients for isolated LVAD support in the era of continuous-flow mechanical circulatory support devices.

Prediction of right ventricular failure after continuous flow left ventricular assist device implantation

“…LVADs have decreased the unacceptable mortality that was previously observed in advanced heart failure patients, particularly in those waiting on the heart transplant list. 15 [11][12][13] In our study, EUROMACS score predicted RVF after Dang et al 23 found that elevated CVP independently predict RVF after LVAD. Fukamachi et al 24 found that low mean PAP was more common in patients with biven-tricular assist device (BiVAD).…”

“…Prior prediction scores had mostly been based on those earlier generation LVADs; which necessitated newer risk models for predicting RVF after CF‐LVAD implantation. In this context; CRITT, ALMA, and EUROMACS risk scores were all composed of five variables and outperformed older RVF prediction models 11‐13 . In our study, EUROMACS score predicted RVF after LVAD implantation with an AUC of 0.789 (CI: 95%, 0.657‐0.921) which is a near‐excellent level of discrimination.…”

Right heart failure considerations in pediatric ventricular assist devices

“…Previous cardiac surgery 30 MELD-XI Score >17 29 Vasopressor requirement (Norepinephrine, vasopressin, phenylephrine) 31 Inotrope dependency 18,28 and ≥3 inotropic agents 27 Mechanically ventilated 12,32,33 Continuous renal replacement therapy 12…”

Right Ventricular Function in Chronic Heart Failure: From the Diagnosis to the Therapeutic Approach

“…All previously discussed echocardiographic indices may be useful to assess RV function and should be considered together with clinical, hemodynamic, and biochemical parameters for predicting right heart failure [ 83 ]. However, the lack of a uniform definition of RHF, the retrospective setting of the principle studies, and the single-center small populations examined, probably make the evaluation of a reliable score very challenging [ 84 , 85 , 86 , 87 , 88 , 89 ]. In a recent meta-analysis [ 90 ], several parameters (clinical, biochemical, hemodynamic, and echocardiographic) have been evaluated in 4428 patients, but none of these were able to accurately identify patients at risk for RHF.…”