A noninvasive alternative in the STOP-RVF score: preoperative right ventricular to pulmonary artery uncoupling for predicting post-LVAD right ventricular failure

Background Right ventricular failure (RVF) remains a major complication after implantation of durable left ventricular assist devices (LVADs). Recently, the STOP-RVF score has been proposed to predict RVF after LVAD implantation. Although the ratio of right atrial pressure to pulmonary capillary wedge pressure (RAP/PCWP) is a key component of this score, its measurements require invasive heart catheterization. In contrast, right ventricular-pulmonary artery uncoupling, assessed by the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP), is a valuable prognostic marker in patents with heart failure and can be measured noninvasively and accurately using echocardiography. Purpose This study aimed to assess the usefulness of preoperative TAPSE/PASP as an alternative to RAP/PCWP in the STOP-RVF score for predicting RVF after LVAD implantation. Methods The STOP-RVF score was calculated for each patient. This score is composed of 11 factors measured prior to LVAD implantation, including non-ischemic cardiomyopathy, use of intra-aortic balloon pump (IABP), use of Impella or veno-arterial extracorporeal membrane oxygenation (VA-ECMO), LVAD configuration, INTERMACS profiles 1-2, RAP/PCWP, use of angiotensin-converting enzyme inhibitors (ACEIs), platelet count, and serum sodium, albumin, and creatinine levels. A modified risk model was developed, replacing RAP/PCWP with TAPSE/PASP, and the predictive performance of both models was compared. Post-LVAD RVF was defined as the need for inotropic support for more than two weeks following LVAD implantation. Results This study included 119 adult patients who underwent LVADs implantation at our institute between October 2008 and December 2024. The median age was 48 years and 70% were male. Post-LVAD RVF occurred in 50% of the patients. Pre-implant TAPSE/PASP was significantly lower in patients who developed RVF compared to those who did not (RVF(+): 0.340 [0.275, 0.460] mm/mmHg, RVF(-):0.408 [0.318, 0.598] mm/mmHg, p=0.048). In univariate analysis, TAPSE/PASP was associated with post-LVAD RVF (odds ratio [OR]: 0.059; 95% confidence interval [CI]: 0.006–0.548, P=0.013), and this association remained significant even after adjustment for the STOP-RVF score minus RAP/PCWP (OR: 0.062; 95% CI: 0.006–0.601, p=0.0165). Comparison of area under the curve showed no significant difference between the original STOP-RVF score and the modified model (STOP-RVF: 0.643 vs. modified model: 0.610, p=0.607). Conclusions Right ventricular–pulmonary artery uncoupling, assessed by the TAPSE/PASP at the time of pre-LVAD evaluation, can serve as a viable alternative to RAP/PCWP in the STOP-RVF score for predicting post-LVAD RVF.