a validated practical risk score to predict the need for rvad after continuous-flow lvad sk singh md...
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![Page 1: A Validated Practical Risk Score to Predict the Need for RVAD after Continuous-flow LVAD SK Singh MD MSc, DK Pujara MBBS, J Anand MD, WE Cohn MD, OH Frazier](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e215503460f94b0ddfe/html5/thumbnails/1.jpg)
A Validated Practical Risk Score
to Predict the Need for RVAD after
Continuous-flow LVAD
SK Singh MD MSc, DK Pujara MBBS, J Anand MD,WE Cohn MD, OH Frazier MD, HR Mallidi MD
Division of Transplant & Assist Devices, Baylor College of Medicine
Houston, Texas, USA
95th Annual AATS Meeting, Seattle, WAApril 28th, 2015
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Disclosures
The authors have NO disclosures relevant to this research project.
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Background
RV failure after LVAD implant occurs in 20-50% of patients.
Severe RV failure post-LVAD, requiring RVAD support has an incidence of 10-25%.
Kormos et al. JTCVS 2010;139:1316-24
The causes are multi-factorial.
RV failure & RVAD after LVAD are well described as significant, independent risk factors for morbidity & mortality.
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BackgroundIdentifying patients high risk for RVAD after LVAD, may improve outcomes via:
• Peri-operative RV optimization• Lower threshold for RVAD support• Alternate strategies (Transplant, TAH, planned
BiVAD)Existing risk scores are limited:
• RV failure outcome, vs RVAD• Inconsistent variables• Few reproduced• Small sample sizes• Based on univariate analyses• Include obsolete pulsatile LVADs• None have been robustly
validated
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Objective
To review the largest single-center experience with CF LVADS to create a simple, portable & robustly validated risk score, that accurately predicts patients at risk for a RVAD after CF LVAD.
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Methods
A retrospective review of consecutive patients implanted with a CF LVAD at our single institution (1999–2013)
N = 469 patients.
Stratified by RVAD required during admission for CF LVAD.
n = 42 RVADs (9.0%)
Univariate summary statistics & Kaplan-Meier survival.
Multivariable logistic regression identified predictors of requiring RVAD.
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Methods
Risk Score:
Predictors dichotomized at clinically relevant thresholds; weighted odds ratios
Created simple acronym & simple to remember risk coefficients
ROC AUC c-statistics were calculated for accuracy
Validated internally – Bootstrapping (case resampling)
Validated prospectively - 2014 patient cohort (N=78)
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Baseline Characteristics CF LVAD (n=427) +RVAD (n=42)
Age (years) 54 + 14 54 + 15
Ischemic Etiology 175 (41%) 20 (48%)
Bridge-to-transplant 254 (59%) 26 (62%)
INTERMACS 1 or 2 219 (53%)* 31 (77%)*
Inotropic Support 361 (84%)* 41 (98%)*
Vasopressor Support 59 (14%)* 12 (29%)*
Pre-operative temporary circulatory support
Extra-corporal membrane oxygenation (ECMO)**
Abiomed Impella or TandemHeart**
Intra-aortic balloon pump (IABP)**
214 (50%)*
1 (0.2%)
63 (14.8%)*
184 (43.1%)*
30 (71%)*
2 (4.8%)
12 (28.6%)*
24 (57.1%)*
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Baseline Characteristics
CF LVAD (n=427) +RVAD (n=42)
Diabetes 178 (42%) 15 (36%)
Chronic Obstructive Pulmonary Disease 55 (13%) 3 (7%)
Renal Replacement Therapy 20 (5%)* 9 (21%)*
Hemoglobin (g/dL) 11.7+2.1 11.1+1.9
White blood count (106/mL) 9.0+4.1* 11.6+5.4*
Sodium (mEq/L) 135+4.5 136+6.2
Creatinine (mg/dL) 1.4+0.7 1.6+0.8
Albumin (g/dL) 3.7 + 1.4* 3.2 + 0.5*
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Hemodynamics
CF LVAD (n=427) +RVAD (n=42)
CI (L/min/m2) 1.9 + 0.6 1.9 + 0.6
PCWP (mmHg) 25 + 10 23 + 9
CVP (mmHg) 12 + 7 14 + 9
PVR (Wood’s Units) 3.5 + 2.7 4.4 + 2.7
LVEDD (cm) 6.7 + 1.1* 6.1 + 1.3*
TR (mod–sev) 170 (43%)* 24 (60%)*
MR (mod–sev) 230 (57%) 25 (63%)
RV depression (mod-sev) 287 (73%) 32 (86%)
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Operative CF LVAD (n=427) +RVAD (n=42)
Previous Sternotomy 144 (34%)* 21 (50%)*
Operative Approach
Sternotomy
Thoracotomy
Subcostal/Other
366 (86%)
37 (9%)
19 (5%)
35 (83%)
6 (14%)
1 (2%)
CPB (minutes) 84 + 48* 128 + 66*
Concomitant Procedure
Atrial septal defect repair**
Tricuspid valve repair/replacement**
Mitral valve repair/replacement**
Aortic valve repair/replacement**
Left ventricle geometry restoration**
Coronary artery bypass grafting**
159 (37%)
45 (10.5%)
7 (1.6%)*
49 (11.5%)
16 (3.7%)
29 (6.8%)
14 (3.3%)
22 (52%)
7 (16.7%)
3 (7.1%)*
4 (9.5%)
2 (4.8%)
4 (9.5%)
3 (7.1%)
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Predictors of RVAD
OR (95% CI)
P-value
Tricuspid regurgitation (1-4) 1.6 (1.1-
2.5)
0.03
Renal Replacement Therapy
(yes/no)
2.9 (1.1-
8.2)
0.04
Albumin (g/dL) 0.3 (0.1-
0.6)
<0.001
LVEDD (cm) 0.6 (0.4-
0.8)
0.01
Previous sternotomy 1.7 (0.8-
3.5)
0.2
Vasopressor use
preoperatively
1.4 (0.6-
3.6)
0.5
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“TRAPPS”
Predictor
Odds Ratio
TRAPPS
Score
(Total = 27)
Tricuspid regurgitation (any) 2.5 5
Renal Replacement Therapy
(yes/no)
3.5 7
Albumin (low; <3.5 g/dL) 2.6 5
Previous sternotomy (yes/no) 1.7 3
VasoPressor required (yes/no) 1.8 4
Small LV cavity size (LVEDD <6
cm)
1.5 3
TRAPPS SCORE Probability of RVAD
Low risk (0-5)
Intermediate risk (6-16)
High risk (17-27)
2.5%
10%
25%
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Accuracy (N=469)
TRAPPS (continuous) TRAPPS (risk groups)
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Validation - Bootstrapping
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Validation – Prospective (n=78)
TRAPPS (continuous) TRAPPS (risk groups)
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Conclusions
Severe RV failure requiring RVAD after CF LVAD is a significant risk factor for considerable early mortality.
This review of the largest, single-center CF LVAD experience found a 9% incidence of RVAD after CF LVAD. TR (any)
Renal replacement therapyAlbumin (<normal)
Previous sternotomyPressor requirementSmall LV cavity (<6cm)
The TRAPPS risk score, is a simple, portable, accurate & validated, pre-operative score to identify patients at risk for RVAD after CF LVAD.
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Conclusions
The TRAPPS variables are intuitive & reproduced in literature.
The score is novel in its robust validation retrospectively, prospectively & derived from a large cohort of solely CF LVADs.
Limitations include external validation (pending), and exclusion of important intra-operative variables (i.e. transfusions).
While TRAPPS accurately identifies those at risk for RVAD, there remains a large margin where further aspects of a heart failure program’s practice may impact RVAD incidence.
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A Validated Practical Risk Score
to Predict the Need for RVAD after
Continuous-flow LVAD
SK Singh MD MSc, DK Pujara MBBS, J Anand MD,WE Cohn MD, OH Frazier MD, HR Mallidi MD
Division of Transplant & Assist Devices, Baylor College of Medicine
Houston, Texas, USA
95th Annual AATS Meeting, Seattle, WAApril 28th, 2015