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

Presented at the 28th Annual Meeting of the ISHLT, April 2008, Boston ,MA.
https://doi.org/10.1016/j.healun.2008.09.006Get rights and content

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 pre-operative 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 liters/min/m2 (odds ratio [OR] 5.7), RV stroke work index ≤0.25 mm Hg · liter/m2 (OR 5.1), severe pre-operative RV dysfunction (OR 5.0), pre-operative creatinine ≥1.9 mg/dl (OR 4.8), previous cardiac surgery (OR 4.5) and systolic blood pressure ≤96 mm Hg (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 pre-operative RV dysfunction, creatinine, previous cardiac surgery and systolic blood pressure. Using these data, we constructed an algorithm that can predict which LVAD patients will require RVAD with >80% sensitivity and specificity.

Section snippets

Patients

All 266 patients who underwent LVAD implantation at the Hospital of the University of Pennsylvania from April 1995 to June 2007 were retrospectively reviewed. Of these, 99 (37%) required RVAD support. The remaining 167 (63%) received isolated LVAD support, and it was these patients who comprised the study groups.

Devices

Multiple devices were used throughout the study period (Table 1, Table 2). These included the BioMedicus Perfusion System (Medtronic, Inc., Littleton, MA), TCI IP (Thermo Cardiosystems,

Univariate Analysis

Table 3 shows demographics and patient characteristics. BiVAD support was required more commonly for female patients (p = 0.0011) and those with smaller body surface area (BSA, p = 0.0029). Results of clinical factor comparisons are shown in Table 4. Severe pre-operative RV dysfunction, mechanical ventilation, previous cardiac surgery, use of an intra-aortic balloon pump (IABP), pre-operative mechanical circulatory support and non-separation from cardiopulmonary bypass were all present in

Discussion

The most effective treatment for end-stage heart failure is cardiac transplantation.27, 28 Discrepancy between the number of donors and those waiting for transplantation causes many potential recipients to die before transplantation, and yields lengthy waiting times for many who ultimately receive transplants. VADs have extended the time that moribund heart failure patients can survive while waiting for transplantation, and are also used successfully for long-term therapy.1, 2, 3, 4, 5, 6, 7, 8

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This work was funded by NIH grant HLO72812 (Y.J.W.), an ISHLT Research Fellowship (J.R.F.III) and NIH grant HLO7843 (J.R.F.).

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