Determining the individualized probability of myocardial recovery: The multicenter RecoverHeart calculator

BACKGROUND: Recent reports from UNOS and INTERMACS highlight that left ventricular assist devices (LVADs) remain underutilized as a bridge-to-recovery (BTR) strategy, despite data from registries and other studies demonstrating that a meaningful subset of patients experience substantial improvements in cardiac structure and function during LVAD support. A reliable tool to estimate the likelihood of cardiac recovery could aid clinicians and heart failure (HF) patients in making informed decisions when considering advanced therapies such as LVAD implantation and heart transplantation. OBJECTIVES: To develop and externally validate a practical calculator estimating an individual patient's likelihood of cardiac recovery during LVAD support. METHODS: The derivation cohort included chronic HF patients supported with continuous-flow LVADs from 5 institutions. An external validation cohort comprised patients from 4 additional institutions. The primary model endpoint was "significant reverse remodeling," defined as achieving LVEF ≥40% and LV end-diastolic diameter ≤6 cm within 1 year of LVAD implantation. A multivariable prediction model estimating the individualized probability of this outcome was developed and externally validated as the RecoverHeart calculator. RESULTS: The derivation cohort included 509 patients, and the validation cohort comprised 375 patients. Significant reverse remodeling was observed in 76 patients (14.9%) in the derivation cohort and 42 patients (11.2%) in the validation cohort. Key preimplant predictors included female sex, shorter HF duration, non-ischemic cardiomyopathy, and smaller left ventricular end-diastolic diameter. The RecoverHeart calculator demonstrated good discrimination, with a C statistic of 0.72 (95% CI: 0.66-0.79) in the derivation cohort and 0.75 (95% CI: 0.67-0.84) in the validation cohort. The model stratified patients across a wide range of predicted probabilities for significant reverse remodeling (0.2%-67.6%) and outperformed previously published models and individual predictors. CONCLUSIONS: The RecoverHeart calculator is a practical and validated tool that estimates the individualized probability of significant reverse remodeling in LVAD patients. By informing patient selection and counseling, it may facilitate shared decision-making, help address the underutilization of LVADs as BTR therapy, and maximize the therapeutic benefits of both LVAD and heart transplantation.