Derivation and Validation of a Novel Right-Sided Heart Failure Model After Implantation of Continuous Flow Left Ventricular Assist Devices

Abstract

ARTICLE ORIGINAL RESEARCH ARTICLEEditorial, see p XXX BACKGROUND: The aim of the study was to derive and validate a novel risk score for early right-sided heart failure (RHF) after left ventricular assist device implantation. METHODS:The European Registry for Patients with Mechanical Circulatory Support (EUROMACS) was used to identify adult patients undergoing continuous-flow left ventricular assist device implantation with mainstream devices. Eligible patients (n=2988) were randomly divided into derivation (n=2000) and validation (n=988) cohorts. The primary outcome was early (<30 days) severe postoperative RHF, defined as receiving short-or long-term rightsided circulatory support, continuous inotropic support for ≥14 days, or nitric oxide ventilation for ≥48 hours. The secondary outcome was all-cause mortality and length of stay in the intensive care unit. Covariates found to be associated with RHF (exploratory univariate P<0.10) were entered into a multivariable logistic regression model. A risk score was then generated using the relative magnitude of the exponential regression model coefficients of independent predictors at the last step after checking for collinearity, likelihood ratio test, c index, and clinical weight at each step.RESULTS: A 9.5-point risk score incorporating 5 variables (Interagency Registry for Mechanically Assisted Circulatory Support class, use of multiple inotropes, severe right ventricular dysfunction on echocardiography, ratio of right atrial/ pulmonary capillary wedge pressure, hemoglobin) was created. The mean scores in the derivation and validation cohorts were 2.7±1.9 and 2.6±2.0, respectively (P=0.32). RHF in the derivation cohort occurred in 433 patients (21.7%) after left ventricular assist device implantation and was associated with a lower 1-year (53% versus 71%; P<0.001) and 2-year (45% versus 58%; P<0.001) survival compared with patients without RHF. RHF risk ranged from 11% (low risk score 0-2) to 43.1% (high risk score >4; P<0.0001). Median intensive care unit stay was 7 days (interquartile range, 4-15 days) versus 24 days (interquartile range, 14-38 days) in patients without versus with RHF, respectively (P<0.001). The c index of the composite score was 0.70 in the derivation and 0.67 in the validation cohort. The EUROMACS-RHF risk score outperformed (P<0.0001) previously published scores and known individual echocardiographic and hemodynamic markers of RHF. CONCLUSIONS:This novel EUROMACS-RHF risk score outperformed currently known risk scores and clinical predictors of early postoperative RHF. This novel score may be useful for tailored risk-based clinical assessment and management of patients with advanced HF evaluated for ventricular assist device therapy. 1,2 Early post-LVAD mortality is due partly to the development of right-sided HF (RHF) in the early post-LVAD phase. 3 The pathophysiology of RHF, however, is not well known.4,5 Post-LVAD RHF has been reported to be between 4% and 50%, 6-10 and RHF-associated 6-month mortality was seen in up to 29% of patients ...

Risk factors of early right ventricular failure in patients undergoing LVAD implantation with intermediate Intermacs profile for advanced heart failure

“…BUN, MDRD 4, Bil, and MELD score, as markers of chronic end‐organ dysfunction, predicted eRVF in our study. Previous studies have observed that patients with eRVF usually have higher Bil, transaminases, BUN, and creatinine levels 5,6,14,15 but the inclusion of patients in InM 1‐2 makes it difficult to discriminate consequences of acute organ dysfunction from those secondary to chronic RV failure. Chronic HFrEF is accompanied by hemodynamic and neurohormonal changes that eventually lead to cardiorenal syndrome and hepatic dysfunction 16 .…”

“…The larger recent studies including continuous‐flow LVAD are from Kormos et al 14 and Atluri et al 24 However, these studies did not include the currently used mainstream LVADs and both reported a large number of patients in shock or with a BVAD. Even the most recent studies involving LVAD registries, like INTERMACS 25 or the most recent study from the EUROMACS registry, 15 included 53% and 43%, respectively, of patients in critical clinical conditions.…”

When VAD Things Happen to Good People

“…The underlying mechanism and management of several morbid and mortal left ventricular assist device (LVAD) complications are beyond contemporary understanding but are sufficiently frequent to be considered common. The paper by Soliman in this issue of Circulation adds clarity to the question about why VAD things happen to good people by defining pre-operative risk factors that predispose patients to the development of right heart failure following implantation of a left-sided mechanical blood pump (2).…”

12 Effectiveness of simultaneous cardiac resynchronisation therapy in surgical valvular patients with severe heart failure

“…pulmonary vascular resistance or PVR) has been stressed to optimise the patient obtaining a better result of VAD implantation. 5 Though rheumatic heart disease (RHD) is on the decline, it remains an important cause of heart failure (HF) in many developing countries including India. It is estimated that about 10%-15% of all HF in India is attributable to RHD.…”