Risk Factors Associated with Right Ventricular Assist Device Implantation: Insights from INTERMACS

To investigate pre-implant variables associated with RVAD use in pts undergoing CF-LVAD surgery. Pts in INTERMACS registry from 6/06 to 3/14 who underwent CF-LVAD surgery (n=9978) were examined for concurrent or subsequent RVAD use within 14d of LVAD. Risk factors for RVAD were assessed with stepwise logistic regression using univariate p-value < 0.05. Model performance was assessed with ROC analysis for the outcomes of 1) early RVAD and 2) combined RVAD or death within 14d. Log-rank test and Cox-PH models were used to compare survival between pts with and without RVAD. 386 pts (3.9%) required an RVAD within 14d of LVAD. Characteristics associated with RVAD use are listed in the Table. INTERMACS pt profiles 1 & 2 as well as need for preoperative ECMO or dialysis/UF were independently associated with RVAD. Hemodynamic determinants included elevated right atrial and reduced pulmonary artery pulse pressure (systolic - diastolic). Other notable predictors included severe pre-implant tricuspid (TV) regurgitation and history of prior cardiac surgery. Concomitant procedures other than TV repair at time of LVAD were also associated with RVAD. The final model demonstrated good performance for RVAD implant (AUC 0.78) and the combined end-point of RVAD or death within 14d (AUC 0.73). Patients requiring RVAD had decreased survival: 1- and 6-mo 78.1% and 63.6% vs. 95.8% and 87.9% for pts receiving isolated LVAD (p<0.0001). Adjusting for baseline risk, RVAD remained associated with increased risk of death: HR 2.76 (95% CI 2.34-3.24). Correlates of overall severity of illness, including markers of end-organ dysfunction and profiles of hemodynamic instability, are associated with RVAD implantation.Tabled 1Risk factors for RVAD use in CF-LVAD recipientsVariableOdds Ratio⁎OR per unit increase for continuous variables95% CIp-valueINTERMACS Profile 1 (vs other)2.79(2.00, 3.89)<0.0001INTERMACS Profile 2 (vs other)1.98(1.49, 2.64)<0.0001Creatinine (mg/dL)1.25(1.07, 1.46)0.005Total Bilirubin (mg/dL)1.13(1.04, 1.23)0.003INR1.50(1.02, 2.22)0.04WBC (K/UL)1.04(1.01, 1.07)0.008Prior CABG/valve surgery1.70(1.34, 2.14)<0.0001Tricuspid valve repair at time of LVAD1.06(0.78, 1.45)0.70Other concomitant surgery at LVAD1.47(1.14, 1.88)0.003Severe Tricuspid Regurgitation1.61(0.78, 1.45)0.002LV end diastolic diameter (mm)0.80(0.67, 0.95)0.01Right atrial pressure (mmHg)1.05(1.03, 1.08)0.0001Pulmonary artery pulse pressure (mmHg)0.96(0.94, 0.98)0.0002Stroke volume (per 10ml increase)0.89(0.80, 0.99)0.03Dialysis or ultrafiltration prior to LVAD1.67(1.08, 2.57)0.02ECMO preoperative (yes vs. no)2.71(1.82, 4.05)<0.0001 OR per unit increase for continuous variables Open table in a new tab