Clinical Research
Heart Failure
The Right Ventricular Failure Risk Score: A Pre-Operative Tool for Assessing the Risk of Right Ventricular Failure in Left Ventricular Assist Device Candidates

https://doi.org/10.1016/j.jacc.2008.03.009Get rights and content
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Objectives

This study sought to develop a model that estimates the post-operative risk of right ventricular (RV) failure in left ventricular assist device (LVAD) candidates.

Background

Right ventricular failure after LVAD surgery is associated with increased morbidity and mortality, but identifying LVAD candidates at risk for RV failure remains difficult.

Methods

A prospectively collected LVAD database was evaluated for pre-operative clinical, laboratory, echocardiographic, and hemodynamic predictors of RV failure. Right ventricular failure was defined as the need for post-operative intravenous inotrope support for >14 days, inhaled nitric oxide for ≥48 h, right-sided circulatory support, or hospital discharge on an inotrope. An RV failure risk score (RVFRS) was created from multivariable logistic regression model coefficients, and a receiver-operating characteristic curve of the score was generated.

Results

Of 197 LVADs implanted, 68 (35%) were complicated by post-operative RV failure. A vasopressor requirement (4 points), aspartate aminotransferase ≥80 IU/l (2 points), bilirubin ≥2.0 mg/dl (2.5 points), and creatinine ≥2.3 mg/dl (3 points) were independent predictors of RV failure. The odds ratio for RV failure for patients with an RVFRS ≤3.0, 4.0 to 5.0, and ≥5.5 were 0.49 (95% confidence interval [CI] 0.37 to 0.64), 2.8 (95% CI 1.4 to 5.9), and 7.6 (95% CI 3.4 to 17.1), respectively, and 180-day survivals were 90 ± 3%, 80 ± 8%, and 66 ± 9%, respectively (log rank for linear trend p = 0.0045). The area under the receiver-operating characteristic curve for the RVFRS (0.73 ± 0.04) was superior to that of other commonly used predictors of RV failure (all p < 0.05).

Conclusions

The RVFRS, composed of routinely collected, noninvasive pre-operative clinical data, effectively stratifies the risk of RV failure and death after LVAD implantation.

Abbreviations and Acronyms

AST
aspartate aminotransferase
AUC
area under the curve
CI
confidence interval
ECMO
extracorporeal membrane oxygenation
iNO
inhaled nitric oxide
LV
left ventricle/ventricular
LVAD
left ventricular assist device
OR
odds ratio
PA
pulmonary artery
PVR
pulmonary vascular resistance
RA
right atrial
RV
right ventricle/ventricular
RVAD
right ventricular assist device
RVFRS
right ventricular failure risk score(s)
RVSWI
right ventricular stroke work index

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