title: Validation of clinical scores for right ventricular failure prediction after implantation of continuous-flow left ventricular assist devices.
abstract: BACKGROUND
  Several clinical prediction schemes for right ventricular failure (RVF) risk after left ventricular assist device (LVAD) implantation have been developed in both the pulsatile- and continuous-flow LVAD eras. The performance of these models has not been evaluated systematically in a continuous-flow LVAD cohort.
  
  
  METHODS
  We evaluated 6 clinical RVF prediction models (Michigan, Penn, Utah, Kormos et al, CRITT, Pittsburgh Decision Tree) in 116 patients (age 51 ± 13 years; 41.4% white and 56.0% black; 66.4% men; 56.0% bridge to transplant, 37.1% destination therapy, 17.4% bridge to decision) who received a continuous-flow LVAD (HeartMate II: 79 patients, HeartWare: 37 patients) between 2008 and 2013.
  
  
  RESULTS
  Overall, 37 patients (31.9%) developed RVF, defined: as pulmonary vasodilator use for ≥48 hours or inotrope use for ≥14 days post-operatively; re-institution of inotropes; multi-organ failure due to RVF; or need for mechanical RV support. Median (Quartile 1 to Quartile 3) time to initial discontinuation of inotropes was 6 (range 4 to 8) days. Among scores, the Michigan score reached significance for RVF prediction but discrimination was modest (C = 0.62 [95% CI 0.52 to 0.72], p = 0.021; positive predictive value [PPV] 60.0%; negative predictive value [NPV] 75.8%), followed by CRITT (C = 0.60 [95% CI 0.50 to 0.71], p = 0.059; PPV 40.5%; NPV 72.2%). Other models did not significantly discriminate RVF. The newer, INTERMACS 3.0 definition for RVF, which includes inotropic support beyond 7 days, was reached by 57 patients (49.1%). The Kormos model performed best with this definition (C = 0.62 [95% CI 0.54 to 0.71], p = 0.005; PPV 64.3%; NPV 59.5%), followed by Penn (C = 0.61), Michigan (C = 0.60) and CRITT (C = 0.60), but overall score performance was modest.
  
  
  CONCLUSIONS
  Current schemes for post-LVAD RVF risk prediction perform only modestly when applied to external populations.
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia. Electronic address: akaloge@emory.edu.
authors.forename: Andreas P
authors.initials: AP
authors.lastname: Kalogeropoulos
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: Anita
authors.initials: A
authors.lastname: Kelkar
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: Jeremy F
authors.initials: JF
authors.lastname: Weinberger
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: Alanna A
authors.initials: AA
authors.lastname: Morris
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: Vasiliki V
authors.initials: VV
authors.lastname: Georgiopoulou
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: David W
authors.initials: DW
authors.lastname: Markham
authors.affiliation: Division of Cardiology, Stony Brook University, Stony Brook, New York.
authors.forename: Javed
authors.initials: J
authors.lastname: Butler
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Georgia.
authors.forename: J David
authors.initials: JD
authors.lastname: Vega
authors.affiliation: Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Smith
mesh_terms: D005260:Female; D005544:Forecasting; D006333:Heart Failure / Q000175:diagnosis*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis*; D011474:Prosthesis Design; D018570:Risk Assessment; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis*
keywords: echocardiography; heart failure; left ventricular assist device; right ventricle failure; risk prediction model