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.

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

6. Clinical Challenges
Cardio-renal Syndrome

7. Clinical Challenges
Effect of prolonged Cardio-renal Syndrome.

8. Clinical Challenges
Narrow therapeutic window (Mean Pressure vs Volume)

9. Clinical Challenges
Right Ventricular Dysfunction and Liver function act on outcome

10. Clinical Setting

11. • How to avoid or escape ?
- Scores (prevention)
- Treatment strategies (army)
Right Ventricular Failure

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

16. Characteristics

17. LVAD device n. 135
HeartMate II 56
HeartWare HVAD 30
CentriMag 20
HeartMate III 13
Jarvik 2000 6
HeartMate XVE 6
Heart Assist 5 1
Berlin Heart Incor 1
Berlin Heart Excor 1
Thoratec PVAD 1
LVAD population

18. RVAD device LVAD device n. 71
CentriMag HeartMate II 27
CentriMag CentriMag 20
Thoratec PVAD Thoratec PVAD 10
Berlin Heart Excor Berlin Heart Excor 5
CentriMag HeartWare HVAD 4
HeartWare HVAD HeartWare HVAD 3
CentriMag HeartMate III 1
Thoratec iVAD Thoratec iVAD 1
BVAD population

19. LVAD Group n.135 BVAD Group n.71 P Value
Age (yy) 54.1 ± 1.6 57.3 ± 2.6 ns
Gender (female, %) 15 (11.1%) 22 (30.1%) 0.05
Etiology
Ischemic DCMP 87 (64.4%) 19 (26.7%) 0.03
Non-Ischemic DCMP 48 (35.5%) 52 (73.2%) 0.03
BMI (kg/m2) 25.8 ± 3.2 29.8 ± 4.3 ns
BMI >30 18 (13.3%) 29 (40.8%) 0.04
ICD (n,%) 98 (72.5%) 58 (81.6%) ns
Prior Cardiac Surgery (n,%) 13 (9.6%) 18 (25.3%) 0.04
Creatinine 1.36 ± 0.6 1.67 ± 1.4 ns
BUN 42.1 ± 28.7 58.1 ± 38.8 ns
Total Bilirubin 1.2 ± 0.3 1.6 ± 0.6 ns
AST 22.1 ± 8.8 29.7 ± 10.7 ns
ALT 26.2 ± 15.6 33.7 ± 12.7 ns
INR 1.32 ± 0.62 1.73 ± 0.81 ns
Haemoglobin 12.1 ± 1.3 11.5 ± 1.1 ns
Haematocrit 32.5 ± 5.6 33.2 ± 6.1 ns
Leukocytes (x1000)/ml 6.9 ± 4.7 13.3 ± 3.9 0.04
Platelets (x1000/ml) 156.5 ± 119.5 160.7 ± 117.6 ns
Stroke/TIA 7 (5.1%) 4 (5.6%) ns
Diabetes 35 (25.9%) 17 (23.9%) ns
Atrial Fibrillation 45 (33.3%) 21 (29.5%) ns
Peripheral Vasculopathy 47 (34.8%) 17 (23.9%) ns
MELD XI >17 10 (7.4%) 22 (30.1%) 0.001

20. LVAD Group n.135 BVAD Group n.71 P Value
Age (yy) 54.1 ± 1.6 57.3 ± 2.6 ns
Gender (female, %) 15 (11.1%) 22 (30.1%) 0.05
Etiology
Ischemic DCMP 87 (64.4%) 19 (26.7%) 0.03
Non-Ischemic
DCMP
48 (35.5%) 52 (73.2%) 0.03
BMI (kg/m2) 25.8 ± 3.2 29.8 ± 4.3 ns
BMI >30 18 (13.3%) 29 (40.8%) 0.04
ICD (n,%) 98 (72.5%) 58 (81.6%) ns
Prior Cardiac Surgery
(n,%)
13 (9.6%) 18 (25.3%) 0.04
Creatinine 1.36 ± 0.6 1.67 ± 1.4 ns
INR 1.32 ± 0.62 1.73 ± 0.81 ns
Haemoglobin 12.1 ± 1.3 11.5 ± 1.1 ns
Haematocrit 32.5 ± 5.6 33.2 ± 6.1 ns
Leukocytes (x1000)/ml 6.9 ± 4.7 13.3 ± 3.9 0.04
Platelets (x1000/ml) 156.5 ± 119.5 160.7 ± 117.6 ns
Stroke/TIA 7 (5.1%) 4 (5.6%) ns
Diabetes 35 (25.9%) 17 (23.9%) ns
Atrial Fibrillation 45 (33.3%) 21 (29.5%) ns
Peripheral Vasculopathy 47 (34.8%) 17 (23.9%) ns
MELD XI >17 10 (7.4%) 22 (30.1%) 0.001

21. LVAD Group n.135 BVAD Group n.71 P Value
Heart Rate (beats/min) 88.1 ± 22.1 95.2 ± 20.6 ns
LV EF (%) 17.3 ± 9.1 20.1 ± 8.2 ns
Cardiac output (l/min) 3.36 ± 0.96 3.18 ± 0.74 ns
Cardiac index (l/min/m2) 1.90 ± 0.4 2.03 ± 0.7 ns
SVO2 60.2 ± 12.6 57.2 ± 7.7 ns
MSAP 78.3 ± 10.1 81.3 ± 12.1 ns
MPAP 29.9 ± 5.91 21.2 ± 7.01 ns
TPG 9.36 ± 3.88 7.29 ± 3.53 ns
PVR (WU) 2.79 ± 1.31 2.15 ± 1.05 ns
Pulmonary Hypertension
(severe)
52 (38.5%) 8 (11.2%) 0.03
RVSWI (mmHg x ml/m2) 628 ± 210 344 ± 208 0.001
TAPSE 16.9 ± 3.1 9.6 ± 3.1 0.04
Tricuspid regurgitation ≥ 3+ 13 (9.6%) 23 (32.3%) 0.03
PAPi <2 9 (6.6%) 28 (39.4%) 0.001
CVP/PCWP >0.63 12 (8.8%) 29 (40.8%) 0.002
RV short/long Axis ratio >0.63 11 (8.1%) 31 (43.6%) 0.001
RV/LV Diameter ratio >0.72 12 (8.8%) 32 (45.1%) 0.001
Mechanical Ventilation 25 (18.5%) 48 (67.6%) 0.002
CVVH 7 (5.1%) 22 (30.9%) 0.003

22. LVAD Group n.135 BVAD Group n.71 P Value
Heart Rate (beats/min) 88.1 ± 22.1 95.2 ± 20.6 ns
LV EF (%) 17.3 ± 9.1 20.1 ± 8.2 ns
Cardiac output (l/min) 3.36 ± 0.96 3.18 ± 0.74 ns
Cardiac index (l/min/m2) 1.90 ± 0.4 2.03 ± 0.7 ns
SVO2 60.2 ± 12.6 57.2 ± 7.7 ns
MSAP 78.3 ± 10.1 81.3 ± 12.1 ns
MPAP 29.9 ± 5.91 21.2 ± 7.01 ns
TPG 9.36 ± 3.88 7.29 ± 3.53 ns
PVR (WU) 2.79 ± 1.31 2.15 ± 1.05 ns
Pulmonary
Hypertension (severe)
52 (38.5%) 8 (11.2%) 0.03
RVSWI (mmHg x
ml/m2)
628 ± 210 344 ± 208 0.001
TAPSE 16.9 ± 3.1 9.6 ± 3.1 0.04
Tricuspid regurgitation
≥ 3+
13 (9.6%) 23 (32.3%) 0.03
PAPi <2 9 (6.6%) 28 (39.4%) 0.001
CVP/PCWP >0.63 12 (8.8%) 29 (40.8%) 0.002
RV short/long Axis
ratio >0.63
11 (8.1%) 31 (43.6%) 0.001
RV/LV Diameter ratio
>0.72
12 (8.8%) 32 (45.1%) 0.001
Mechanical Ventilation 25 (18.5%) 48 (67.6%) 0.002

23. LVAD Group n.135 BVAD Group n.71 P Value
i.v. Inotropic agents 82 (60.7%) 48 (67.6%) ns
IABP pre 61 (45.1%) 36 (50.7%) ns
ECMO pre 2 (1.4%) - -
INTERMACS level 1 2 (1.4%) - -
INTERMACS level 2-3 102 (75.5%) 58 (81.6%) ns
INTERMACS level 4 42 (31.1%) 13 (18.3%) ns
LVAD indication
Destination therapy 30 (22.2%) 37 (52.1%) 0.02

24. LVAD Group n.135 BVAD Group n.71 P Value
i.v. Inotropic agents 82 (60.7%) 48 (67.6%) ns
IABP pre 61 (45.1%) 36 (50.7%) ns
ECMO pre 2 (1.4%) - -
INTERMACS level 1 2 (1.4%) - -
INTERMACS level 2-3 102 (75.5%) 58 (81.6%) ns
INTERMACS level 4 42 (31.1%) 13 (18.3%) ns
LVAD indication
Destination
therapy
30 (22.2%) 37 (52.1%) 0.02

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

29. ALMA score 4-5

30. Gray Zone (score 2-3)

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)

32. ‘Right V intercostal
Space’
TVR by MIC

33. Percutaneous
RVAD
(Hybrid OR)

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

38. Thanks for your attention!