Why use it

Right heart failure after LVAD implantation carries a high mortality risk and may require RVAD support, prolonged intensive care, and prolonged hospitalization. Accurate preoperative risk stratification enables clinical decision-making around LVAD candidacy, concurrent RVAD implantation (BiVAD), patient counseling, and appropriate resource planning. The EUROMACS-RHF score outperforms older RHF prediction scores (MICHIGAN, Penn, CRITT) in the contemporary LVAD era.

About

The EUROMACS Right Heart Failure (RHF) Risk Score is a validated preoperative scoring tool developed from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) to predict the risk of right heart failure requiring right ventricular assist device (RVAD) support or prolonged inotrope dependency after LVAD implantation. Right heart failure is one of the most serious complications of LVAD implantation, occurring in 20–40% of patients, with early severe RHF (requiring RVAD) associated with mortality exceeding 40–50%. The score incorporates six preoperative variables: INTERMACS profile, severe right ventricular dysfunction on echocardiography, use of preoperative inotropic support, serum bilirubin, creatinine, and hemoglobin. The total score ranges from 0 to 9, stratifying patients into low (0–2), medium (3–4), and high (≥5) risk of post-LVAD RHF. Validation in the EUROMACS registry demonstrated good discrimination (AUC 0.73).

When to use

Preoperative evaluation of all patients under consideration for LVAD implantation
Decision-making around primary BiVAD vs. LVAD-alone implantation strategy
Patient and family counseling about post-LVAD RHF risk
Surgical planning and resource allocation for high-risk LVAD procedures
Multidisciplinary heart failure team discussion prior to LVAD surgery

Formula

EUROMACS-RHF Score (0–9 points): INTERMACS Profile 1 (critical cardiogenic shock): +4 points Severe RV dysfunction on echocardiography: +3 points Preoperative use of inotropic support: +2 points Bilirubin >2 mg/dL (>34 µmol/L): +2 points Creatinine >1.5 mg/dL (>133 µmol/L): +1 point Hemoglobin <10.6 g/dL: +1 point Risk Categories: 0–2: Low risk of severe RHF 3–4: Medium risk ≥5: High risk

Pearls & pitfalls

Post-LVAD RHF is defined as need for RVAD, inhaled NO >48h, or inotropes >14 days postoperatively — the EUROMACS-RHF score predicts this composite endpoint.
INTERMACS Profile 1 (critical cardiogenic shock) carries the highest RHF risk — emergent LVAD implants in cardiogenic shock have up to 40% RHF rates.
Severe echocardiographic RV dysfunction is defined as TAPSE <7.5 mm, RV fractional area change <17%, or RV/LV ratio >1.0 with qualitative severe RV dysfunction.
Bilirubin elevation reflects RV-related hepatic congestion — a marker of chronic right heart failure and portal hypertension that predicts post-LVAD RHF.
The EUROMACS-RHF score AUC of 0.73 is comparable to or better than other published RHF risk scores (Michigan = 0.71, Penn = 0.72).
Optimization strategies before LVAD to reduce RHF risk include: aggressive diuresis, inotropic support, pulmonary vasodilators, and rarely preoperative RVAD or ECMO.
Central venous pressure (CVP)/PCWP ratio >0.63 and right atrial pressure >15 mmHg are hemodynamic predictors of post-LVAD RHF not captured in this score — always review right heart catheterization data.
The score was derived in a European registry — validation in contemporary HeartMate 3 patients is ongoing.

Next steps

Low Risk (0–2): LVAD implantation may proceed with standard perioperative RHF management. Optimize preoperative hemodynamics. Routine postoperative RV monitoring. Medium Risk (3–4): Preoperative optimization of right ventricular function and loading conditions. Consider inhaled pulmonary vasodilators (iNO, epoprostenol) perioperatively. RVAD standby preparation. Experienced center preferred. High Risk (≥5): Highest risk of severe post-LVAD RHF. Consider primary BiVAD implantation or temporary RVAD strategy. Extensive preoperative RV optimization. Implantation should occur only at high-volume MCS centers with RVAD capability. Discuss with patient and family the high risk of complications.

Evidence

Solowiejczyk Y et al.; EUROMACS Investigators. The EUROMACS right-sided heart failure risk score. Eur J Cardiothorac Surg. 2018;54(3):452-459. PMID:29684114. Derived from 2988 LVAD implants across 20 European centers. AUC 0.73 for severe RHF prediction. Score externally validated in subsequent European cohorts.

References

Solowiejczyk Y et al.; EUROMACS Investigators. The EUROMACS right-sided heart failure risk score. Eur J Cardiothorac Surg. 2018;54(3):452-459. — link
Konstam MA et al. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device. Circulation. 2008;118(2):157-164. — link
Bhama JK et al. Clinical experience with the HeartMate 3 Left Ventricular Assist Device. Ann Thorac Surg. 2019;107(5):1372-1378. — link

EUROMACS Right Heart Failure Risk Score

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