Risk stratification of ambulatory patients with advanced heart failure undergoing evaluation for heart transplantation

Tomoko S. Kato, Gerin R. Stevens, Jeffrey Jiang, P. Christian Schulze, Natalie Gukasyan, Matthew Lippel, Alison Levin, Shunichi Homma, Donna Mancini, Maryjane Farr

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Risk stratification of ambulatory heart failure (HF) patients has relied on peak VO2<14 ml/kg/min. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS <4) or heart transplantation (HTx, Status 1A or 1B) within 1 year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the model for end-stage liver disease - albumin score (MELD-A) would be additive prognostic predictors. Methods: We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within 1 year after evaluation. Results: Average age in our cohort was 55 ± 11.1 years, 79.1% were male and 39% had an ischemic etiology (LVEF 21 ± 10.5% and peak VO2 12.6 ± 3.5 ml/kg/min). Fifty outcomes (33.1%) were observed (27 HTxs, 15 VADs and 8 deaths). Univariate logistic regression showed a significant association of RVSWI (OR 0.47, p = 0.036), PCWP (OR 2.65, p = 0.007) and MELD-A (OR 2.73, p = 0.006) with 1-year events. Stepwise regression showed an independent correlation of RVSWI<5 gm-m2/beat (OR 6.70, p < 0.01), PCWP>20 mm Hg (OR 5.48, p < 0.01), MELD-A>14 (OR 3.72, p< 0.01) and peak VO 2<14 ml/kg/min (OR 3.36, p = 0.024) with 1-year events. A scoring system was developed: MELD-A>14 and peak VO2<14 - 1 point each; and PCWP>20 and RVSWI<5 - 2 points each. A cut-off at≥4 demonstrated a 54% sensitivity and 88% specificity for 1-year events. Conclusions: Ambulatory HF patients have significant 1-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of 1-year prognosis. Our findings support early and timely referral for VAD and/or transplant.

Original languageEnglish (US)
Pages (from-to)333-340
Number of pages8
JournalJournal of Heart and Lung Transplantation
Volume32
Issue number3
DOIs
StatePublished - Mar 1 2013

Keywords

  • heart failure
  • heart transplant evaluation
  • mechanical circulatory support
  • prognosis
  • right ventricular dysfunction
  • risk stratification

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine
  • Transplantation

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