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Risk Factors Predictive of Right Ventricular Failure After Left Ventricular Assist Device Implantation

https://doi.org/10.1016/j.amjcard.2009.11.026Get rights and content

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation appears to be associated with increased mortality. However, the determination of which patients are at greater risk of developing postoperative RVF remains controversial and relatively unknown. We sought to determine the preoperative risk factors for the development of RVF after LVAD implantation. The data were obtained for 175 consecutive patients who had received an LVAD. RVF was defined by the need for inhaled nitric oxide for ≥48 hours or intravenous inotropes for >14 days and/or right ventricular assist device implantation. An RVF risk score was developed from the β coefficients of the independent variables from a multivariate logistic regression model predicting RVF. Destination therapy (DT) was identified as the indication for LVAD implantation in 42% of our patients. RVF after LVAD occurred in 44% of patients (n = 77). The mortality rates for patients with RVF were significantly greater at 30, 180, and 365 days after implantation compared to patients with no RVF. By multivariate logistic regression analysis, 3 preoperative factors were significantly associated with RVF after LVAD implantation: (1) a preoperative need for intra-aortic balloon counterpulsation, (2) increased pulmonary vascular resistance, and (3) DT. The developed RVF risk score effectively stratified the risk of RV failure and death after LVAD implantation. In conclusion, given the progressively growing need for DT, the developed RVF risk score, derived from a population with a large percentage of DT patients, might lead to improved patient selection and help stratify patients who could potentially benefit from early right ventricular assist device implantation.

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Methods

The analysis was performed using a prospectively collected database from a large-volume, single center of 175 LVAD patients who underwent implantation from 1993 to 2008. The patients underwent implantation with the HeartMate XVE (n = 82, 47%), HeartMate VE (n = 42, 24%), HeartMate 1000 IP (n = 17, 10%), HeartMate II (n = 25, 14%; all devices manufactured by Thoratec, Pleasanton, California) or the Novacor device (n = 9, 5%; World Heart, Oakland, California). The LVADs were placed as BTT in 58%

Results

Of the 175 patients analyzed, 77 (44%) experienced RVF after LVAD implantation. Of the 77 patients who were diagnosed with RVF, 45 (58%) were treated medically with either inotropes or inhaled nitric oxide, and 32 (42%) required the placement of an RVAD after LVAD implantation. The survival rate between the non-RVF and RVF groups was 96% versus 80% at 30 days (p = 0.0012), 90% versus 70% at 180 days (p = 0.0011; Figure 1), and 83% versus 62% at 365 days (p = 0.002).

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Discussion

RVF in the early postoperative period after LVAD implantation remains a major cause of morbidity and mortality.5, 6, 7, 8, 9, 10, 11 In the present study, we demonstrated a substantial mortality rate associated with perioperative RVF in patients receiving an LVAD for end-stage heart failure. Furthermore, our results have clearly delineated the significant decrease in survival at 30, 180, and 365 days after LVAD implantation using our risk score model. The subgroup with a risk score of ≥12.5 had

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