Preoperative and perioperati̇ve predictors of right ventricular failure after left ventricular assist device implantation

OBJECTIVES: Although preoperative prediction of Right Ventricular Failure (RVF) after Left Ventricular Assist Device(LVAD) implantation is a frequently laboured entity, there isn't a consensus about any parameter. In this trial, we aimed to detect clinical, laboratory, hemodynamic and echocardiographic parameters in order to predict RVF after continuous flow LVAD implantation. METHODS: From March 2013 to April 2014, 42 continuous flow LVAD implanted patients (39 male,3 female; mean age 50,2±12,4) were included in our single center, prospective, observational, case series study. Patients' pre-operative clinical, laboratory, Right Heart Catheterisation(RHC) and echocardiographic findings were evaluated. Post-operative RVF was defined as inotrope dependence for more than 14 days and/or need for RVAD implantation. RESULTS: 24 patients included in the study had ischemic and 18 patients had non-ischemic etiology. 32 patients had HeartWare and 10 patients had HeartMate II. Functional classes were defined according to INTERMACS classification. 8 patients were in INTERMACS I-II, 34 patients were in INTERMACS III-IV. 7 patients(%16,7) had RVF. In 4 patients in INTERMACS I-II(%57,1) and 3 patients(%42,9) in INTERMACS III-IV, RVF was stated. Among clinical data; poor INTERMACS class(p=0,017), low systolic blood pressure(p=0,02) and diastolic blood pressure(p=0,032), fluid retantion in abdominal cavity(ascites)(p=0,009), among RHC findings; increased right atrial pressure(RAP)(p=0,039), among laboratory data; low prealbumin(p=0,003), high bilirubin(p=0,008) and NT-proBNP(p=0,041) levels, among clinical risk scores; high Michigan RVF score and among echocardiographic data; low left ventricular ejection fraction (LVEF) (p=0,012), right ventricular fractional area change(RV-FAC)(p<0,001), tricuspit annuler plane systolic excursion(TAPSE)(p=0,019), right ventricular systolic velocity (RVSm)(p=0,021), right ventricular outflow tract systolic excursion (RVOT-SE)(p<0,001), increased RV diameter(p=0,004), tricuspid annulus diameter(p=0,005), mild to severe tricuspid regurgitation(TR)(p=0,031) and RV-MPI(myocardial performans index)(p=0,007) value were found statistically significant to be associated with RVF. Risk factors by multivariable logistic regression were fluid retantion in abdominal cavity(ascites)(OR:14,2), prealbumin<14 mg/dl(OR:10), total bilirubin>1,5 mg/dl(OR:15), RV diameter>3,2 cm(OR:19,3), RV-FAC<%24(OR:99), RAA>28 cm²(OR:20,2), RV-MPI>0,35(OR:10). RV-FAC<%24 predicted RVF with %95 spesificity and %86 sensitivity(AUC:0,957). CONCLUSIONS: Fluid retantion in abdominal cavity, prealbumin <14 mg/dl, bilirubin > 1,5 mg/dl, RV diameter > 3,2 cm, RV-FAC<%24, RAA > 28cm² and RV-MPI > 0,35 were the most significant predictors for RVF after LVAD implantation. Increased RAP, high tricuspid annulus diameter, mild to severe TR and low RVOT-SE were also other important parameters. Despite our small study population, this information will be a pathfinder for bigger prospective trials with larger study populations.