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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

Jennifer Cowger Matthews, MD^_*, Todd M. Koelling, MD^_*, Francis D. Pagani, MD, PhD and Keith D. Aaronson, MD, MS^_*,_*

^_* Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan
Section of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan.

Manuscript received August 20, 2007; revised manuscript received February 7, 2008, accepted March 4, 2008.

^_* Reprint requests and correspondence: Dr. Keith D. Aaronson, University of Michigan Cardiovascular Center, Room 2169, 1500 East Medical Center Drive, SPC 5853, Ann Arbor, Michigan 48109-5853. (Email: keith{at}med.umich.edu).

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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