The ALMA score from Loforte et al. presented at the ASAIO meeting in Chicago on June 24th. An Useful Decision Supporting Tool available bedside to predict right ventricular failure and even to modify the surgical planning to support/protect right heart and warranting better outcome.
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Asaio 2017: Predicting Right Ventricular Failure in CF-LVAD Era.
1. Predicting Right Ventricular Failure in the Current
Continuous Flow Left Ventricular Assist Device Era
Dr. Cristiano Amarelli.
Monaldi, Azienda dei Colli, Naples
A. Loforte,1 C. Amarelli,2 A. Montalto,3 P. Lilla Della Monica,3 F. Grigioni,1
F. Musumeci,3 G. Marinelli.1
Cardiac 6 - Debate - VADs: Total Artificial Heart (TAH),
Continuous-Flow Biventricular Support or Heart Transplant
2. Right Dysfunction due to long-lasting Left Ventricular Dysfunction.
The challenge of Biventricular Support
3. Right Dysfunction due to long-lasting Left Ventricular Dysfunction.
The challenge of Biventricular Support
4. Right Dysfunction due to long-lasting Left Ventricular Dysfunction.
The challenge of Biventricular Support
5. The challenge of Biventricular Support
Reversing PH and RV dysfunction.
LVAD+ temporary-RVAD
11. • How to avoid or escape ?
- Scores (prevention)
- Treatment strategies (army)
Right Ventricular Failure
12.
13. • We reviewed demographic, echocardiographic,
hemodynamic and laboratory variables for 206 patients
who underwent mechanical circulatory support
implantation between January 2004 and December 2016
(LVAD=135, BVAD=71).
• Sixty preoperative risk factors were compared between
patients who were successfully managed with an
LVAD and those who required a BVAD.
Derivation
14. • We reviewed demographic, echocardiographic,
hemodynamic and laboratory variables for 206 patients
who underwent mechanical circulatory support
implantation between January 2004 and December 2016
(LVAD=135, BVAD=71).
• Sixty preoperative risk factors were compared
between patients who were successfully managed
with an LVAD and those who required a BVAD.
Derivation
15. • Backward stepwise logistic regression
• Akaike information criterion used to determine the
best fit
• A risk model constructed based on the variables
and their respective regression coefficients
Derivation
25. Results
Pts n.206 Lenght of Hospital
stay
(dd)
Htx, Recovery,
Ongoing
at 180 dd
KM Survival at
1 y
No RVF (LVAD) 135 22 (7-126) 119 (88.1 %) 81.3 ± 2 %
RVF (BVAD) 71 34 (2-181) 47 (66.1 %) 58.1 ± 8 %
26. Characteristics OR 95% CI P Value
Destination therapy 2.0 1.7-3.9 0.003
PAPi <2 3.3 1.7-6.1 0.001
RV/LV EDD ratio >0.75 2.7 1.5-5.5 0.001
RVSWi <400
mmHg.mL/m2
4.3 2.5-7.3 <0.001
MELD-XI >17 3.5 1.9-6.9 <0.001
27. Characteristics OR Score P Value
Destination therapy 2.0 1 0.003
PAPi <2 3.3 1 0.001
RV/LV EDD ratio >0.75 2.7 1 0.001
RVSWi <400
mmHg.mL/m2
4.3 1 <0.001
MELD-XI >17 3.5 1 <0.001
ALMA
28. Optimal ALMA Cut-off Value
- For cut-off value = 3.0
Sensitivity 0.8633
Specificity 0.7715
Positive Predictive
Value
0.9345
Negative Predictive
Value
0.2682
31. RV unloading
before Surgery
by CBP
and ‘full
closure’ of
Pericardium at
the end
(Prague school)
‘Partial’ opening of
Pericardium by MIC
(Hannover school)
34. ALMA score factors and predictivity
RV load indepent contractile
reserve OR 3,3
PAPi Factors: PAS-PAD/RA
RVF severity OR 4,3
RVSWI: SV (GC/FC),
BSA, MPAP
Lenght of disease OR 2,7
RV/LV EDD ratio >0.75
Looks time-related geometry
changes
”Eyeball” Assesment OR 2
Device Strategy
Looks Acuteness, Frailty, End-
organ dyfunction,
comorbidities.
Illness severity OR 3,5
MELD Factors: Age, Bilirubin,
Sodium, INR, Creatinin, CVVH
Looks Liver-Gut-Inflammation
CRS
35. Conclusions
• Biventricular Failure represents a real challenge requiring new devices to improve results.
• Bedside available decision tools (DST) may help supported decisions.
36. Alma score encompasses:
– factors related to the right ventricular function
– factors related to the lenght of illness
– factors related to the “milieu” due to prolonged right
ventricular dysfunction.
Low Alma Score is an useful bedside tool to predict
patients at low risk of right ventricular failure post-LVAD.
Conclusions
37. • High Alma Score accurately predicts the need of straightforward
biventricular support/TAH.
• Intermediate value of Alma Score should push toward a tailored
strategy to manage right ventricle during the postoperative
phases while reversing PH and RVF.
• The solutions should be selected on the basis of the predicted
time to reverse pulmonary hypertension and recover a valuable
right ventricular function.
• This score should be validated on large series.
Conclusions