Department of Cardiology, Thoraxcenter (O.I.I.S., S.A., R.M., E.B., O.C.M., F.Z., K.C.)
Department of Cardiology, Thoraxcenter (O.I.I.S., S.A., R.M., E.B., O.C.M., F.Z., K.C.).
Circulation. 2018 Feb 27;137(9):891-906. doi: 10.1161/CIRCULATIONAHA.117.030543. Epub 2017 Aug 27.
The aim of the study was to derive and validate a novel risk score for early right-sided heart failure (RHF) after left ventricular assist device implantation.
The EUROMACS (European Registry for Patients with Mechanical Circulatory Support) was used to identify adult patients undergoing continuous-flow left ventricular assist device implantation with mainstream devices. Eligible patients (n=2988) were randomly divided into derivation (n=2000) and validation (n=988) cohorts. The primary outcome was early (<30 days) severe postoperative RHF, defined as receiving short- or long-term right-sided circulatory support, continuous inotropic support for ≥14 days, or nitric oxide ventilation for ≥48 hours. The secondary outcome was all-cause mortality and length of stay in the intensive care unit. Covariates found to be associated with RHF (exploratory univariate <0.10) were entered into a multivariable logistic regression model. A risk score was then generated using the relative magnitude of the exponential regression model coefficients of independent predictors at the last step after checking for collinearity, likelihood ratio test, c index, and clinical weight at each step.
A 9.5-point risk score incorporating 5 variables (Interagency Registry for Mechanically Assisted Circulatory Support class, use of multiple inotropes, severe right ventricular dysfunction on echocardiography, ratio of right atrial/pulmonary capillary wedge pressure, hemoglobin) was created. The mean scores in the derivation and validation cohorts were 2.7±1.9 and 2.6±2.0, respectively (=0.32). RHF in the derivation cohort occurred in 433 patients (21.7%) after left ventricular assist device implantation and was associated with a lower 1-year (53% versus 71%; <0.001) and 2-year (45% versus 58%; <0.001) survival compared with patients without RHF. RHF risk ranged from 11% (low risk score 0-2) to 43.1% (high risk score >4; <0.0001). Median intensive care unit stay was 7 days (interquartile range, 4-15 days) versus 24 days (interquartile range, 14-38 days) in patients without versus with RHF, respectively (<0.001). The c index of the composite score was 0.70 in the derivation and 0.67 in the validation cohort. The EUROMACS-RHF risk score outperformed (<0.0001) previously published scores and known individual echocardiographic and hemodynamic markers of RHF.
This novel EUROMACS-RHF risk score outperformed currently known risk scores and clinical predictors of early postoperative RHF. This novel score may be useful for tailored risk-based clinical assessment and management of patients with advanced HF evaluated for ventricular assist device therapy.
本研究旨在为左心室辅助装置植入术后早期右心衰竭（RHF）建立并验证一种新的风险评分。
使用 EUROMACS（欧洲机械循环支持患者登记处）识别接受主流装置左心室辅助装置植入的成年患者。符合条件的患者（n=2988）被随机分为推导（n=2000）和验证（n=988）队列。主要结局是早期（<30 天）严重术后 RHF，定义为接受短期或长期右侧循环支持、持续使用≥14 天的正性肌力药物或≥48 小时的一氧化氮通气。次要结局是全因死亡率和重症监护病房的住院时间。在探索性单变量<0.10 时发现与 RHF 相关的协变量被纳入多变量逻辑回归模型。然后，使用独立预测因子的指数回归模型系数的相对大小，在最后一步生成风险评分，在每个步骤检查共线性、似然比检验、c 指数和临床权重后。
建立了一个包含 5 个变量（Interagency Registry for Mechanically Assisted Circulatory Support 分类、使用多种正性肌力药物、超声心动图显示严重右心室功能障碍、右心房/肺毛细血管楔压比值、血红蛋白）的 9.5 分风险评分。推导和验证队列的平均评分分别为 2.7±1.9 和 2.6±2.0（=0.32）。左心室辅助装置植入后，推导队列中 433 例患者（21.7%）发生 RHF，与无 RHF 患者相比，1 年（53%比 71%；<0.001）和 2 年（45%比 58%；<0.001）生存率较低。RHF 风险范围从 11%（低风险评分 0-2）到 43.1%（高风险评分>4；<0.0001）。与无 RHF 患者相比，重症监护病房的中位住院时间分别为 7 天（四分位距，4-15 天）和 24 天（四分位距，14-38 天）（<0.001）。综合评分的 c 指数在推导和验证队列中分别为 0.70 和 0.67。EUROMACS-RHF 风险评分优于（<0.0001）先前发表的评分和已知的 RHF 超声心动图和血流动力学标志物。
这种新的 EUROMACS-RHF 风险评分优于目前已知的术后早期 RHF 风险评分和临床预测因子。这种新的评分可能有助于对接受心室辅助装置治疗的晚期心力衰竭患者进行基于风险的个体化临床评估和管理。
