Prediction of right ventricular failure after continuous flow left ventricular assist device implantation.

Abstract

Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Prediction of this clinical situation in LVAD patients with different clinical scores is still an enigma. The aim of this study is to analyze the predictive power of clinical parameters and risk scores and their combinations to discriminate RVF after LVAD implantation. A retrospective, single center review of 71 patients who underwent continuous flow-LVAD implantation between September 2013 and September 2016, was performed. RVF was defined as need for RVAD and/or administration of inotropic agents more than 14 days after LVAD implantation. Patients with and without RVF were divided into two groups and predictive power of the nine parameters (tricuspid annular plane systolic excursion (TAPSE), Michigan score, Pennsylvania score, central venous pressure/pulmonary artery wedge pressure ratio (CVP/PCWP), and right ventricular stroke work index, pulmonary artery pulsatility index, CRITT score, ALMA score, European registry for patients with mechanical circulatory support (EUROMACS) right heart failure model and their combinations were analyzed to predict postoperative RVF. Of 71 patients, 21 had RVF after implantation. For the variables that can be used to discriminate between RVF and non-RVF groups, the diagnostic performance of the best cut-off points and tests was obtained using receiver operating characteristic (ROC) curve analysis. Discrimination analysis was performed to determine the combinations of tests. For all single risk scores and parameters; the area under the ROC curve (AUC) was below 0.7 which is considered to be a poor level of discrimination except EUROMACS score (AUC: 0.789, P < .001) and CRITT score (AUC: 0.739, P = .004). AUC for the combination of TAPSE and Pennsylvania score was 0.722, combination of Michigan and Pennsylvania scores represented AUC of 0.732 in the analysis. The combination of TAPSE + Pennsylvania score was found to have the highest sensitivity (85%), whereas TAPSE + Michigan score + CVP/PCWP appeared as the most specific (97%) combination. EUROMACS and CRITT scores predict RVF with high discrimination after LVAD implantation. Although, no other single test predicts RVF ideally, combination of risk scores and parameters discriminate RVF acceptably.