Risk Score Derived from Pre-operative Data Analysis Predicts the Need for Biventricular Mechanical Circulatory Support

Abstract

Background Right ventricular (RV) failure after left ventricular assist device (LVAD) placement is a serious complication and is difficult to predict. In the era of destination therapy and the total artificial heart, predicting post-LVAD RV failure requiring mechanical support is extremely important. Methods We reviewed patient characteristics, laboratory values, and hemodynamic data from 266 patients who underwent LVAD placement at the University of Pennsylvania from April 1995 to June 2007. Results Of 266 LVAD recipients, 99 required RV assist device (BiVAD) placement (37%). We compared 36 parameters between LVAD (n=167) and BiVAD patients (n=99) to determine preoperative risk factors for RV assist device (RVAD) need. By univariate analysis, 23 variables showed statistically significant differences between the two groups (P ≤ 0.05). By multivariate logistic regression, cardiac index ≤ 2.2 L/min·m2 (odds ratio [OR] 5.7), RV stroke work index ≤ 0.25 mmHg·mL/m2 (OR 5.1), severe preoperative RV dysfunction (OR 5.0), preoperative creatinine ≥ 1.9 mg/dL (OR 4.8), previous cardiac surgery (OR 4.5), and systolic blood pressure ≤ 96 mmHg (OR 2.9) were the best predictors of RVAD need. Conclusions The most significant predictors for RVAD need were cardiac index, RV stroke work index, severe preoperative RV dysfunction, creatinine, previous cardiac surgery, and systolic blood pressure. Using these, we constructed an algorithm which can predict which LVAD patients will require RVAD with greater than 80% sensitivity and specificity.

Impact of Preoperative Percutaneous Cardiopulmonary Support on Outcome Following Left Ventricular Assist Device Implantation

“…When weaning from CPB, we utilize inotropes, PDEi, and nitric oxide inhalation to maintain adequate LVAD flow. Preoperative cardiac index <2.2 L · min -1 · m -2 is reported to be the most significant predictor of mechanical right ventricular support in LVAD implantation, 17 and that index was below that level in 49% of the present patients without preoperative PCPS. The intraoperative and postoperative management protocol, however, allowed all of the patients without preoperative PCPS to maintain an adequate cardiac output without mechanical right ventricular support at 1 month after LVAD implantation ( Table 5).…”

A UK Single Centre Retrospective Analysis of the Relationship between Haemodynamic Changes and Outcome in Patients Undergoing Prolonged Left Ventricular Assist Device Support

“…We do use TAPSE but RVSWI is currently argued as a better parameter. 16) Whilst the reversibility of pulmonary hypertension during LVAD support is unpredictable, timely implantation is a key determinant of favourable outcome and cost-effectiveness. 7,17) Improving clinical outcomes with current generation devices favour extending LVAD therapy to patients of INTERMACS profile 4 to 6 7,18) but this remains controversial because although the anticipated surgical risk should be lower with better survival, the haemodynamic benefit may be reduced.…”

Implantation of the Syncardia Total Artificial Heart

“…A number of risk factors for RV failure have been identified and several risk scoring systems have been developed. The need for inotropic / intra-aortic balloon pump support, evidence of renal and hepatic dysfunction (elevated creatinine, aspartate aminotransferase, bilirubin), hemodynamic evidence of RV dysfunction (decreased RV stroke work index, increased right atrial / wedge pressures), and echocardiographic evidence of RV dysfunction (RV dilatation, decreased RV ejection fraction / tricuspid annular motion, increased tricuspid regurgitation) have all been identified as risk factors [12][13][14][15] . Nonetheless, determination of risk for RV failure after LVAD placement remains difficult.…”