The model for end-stage liver disease (MELD) predicts early and late outcomes of cardiovascular operations in patients with liver cirrhosis

Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden (MELD-AFP-TBS) score to stratify prognosis after liver resection for hepatocellular carcinoma

INTRODUCTION

Morphologic criteria, such as the Barcelona Clinic Liver Cancer staging system often fail to accurately predict long-term survival among patients undergoing liver resection for hepatocellular carcinoma. We sought to develop a continuous risk score that incorporates established markers of tumor biology and liver function to improve the prediction of overall survival.

METHODS

Data from a multi-institutional database were used to identify patients who underwent curative-intent hepatectomy for hepatocellular carcinoma. A predictive score for overall survival was developed using weighted beta-coefficients from a multivariable Cox regression model.

RESULTS

Among 850 patients, 595 (70.0%) were assigned to the training cohort, and 255 (30.0%) to the test cohort. In the training cohort, multivariable analysis identified the Model of End-Stage Liver Disease (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07), log-transformed alpha-fetoprotein (hazard ratio, 1.07; 95% confidence interval, 1.02-1.13), and tumor burden score (hazard ratio, 1.07; 95% confidence interval, 1.03-1.11) as independent predictors of worse overall survival. The Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score, based on the Cox model, stratified patients into low-risk (n = 466, 78.3%) with a 5-year OS of 70.5% and high-risk (n = 129, 21.7%) with a 5-year OS of 47.0% (P < .001). In the test cohort, the Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score demonstrated superior discriminative accuracy (C-index: 0.72, time-dependent area under the curve 1-year: 0.80, 3-year 0.76, 5-year 0.70) compared with the Barcelona Clinic Liver Cancer staging system (C-index: 0.53, time-dependent area under the curve 1-year: 0.61, 3-year 0.55, 5-year 0.56). An online tool was made accessible at https://jk-osu.shinyapps.io/MELD_AFP_TBS/.

CONCLUSION

The Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score provides a novel, accurate tool for prognostic stratification of patients with hepatocellular carcinoma, identifying high-risk patients who may benefit from alternative treatments to improve outcomes.

The importance of liver function assessment before cardiac surgery: A narrative review

The demand for cardiac surgery procedures is increasing globally. Thanks to an improvement in survival driven by medical advances, patients with liver disease undergo cardiac surgery more often. Liver disease is associated with the development of heart failure, especially in patients with advanced cirrhosis. Cardiovascular risk factors can also contribute to the development of both cardiomyopathy and liver disease and heart failure itself can worsen liver function. Despite the risk that liver disease and cirrhosis represent for the perioperative management of patients who undergo cardiac surgery, liver function is often not included in common risk scores for preoperative evaluation. These patients have worse short and long-term survival when compared with other cardiac surgery populations. Preoperative evaluation of liver function, postoperative management and close postoperative follow-up are crucial for avoiding complications and improving results. In the present narrative review, we discuss the pathophysiological components related with postoperative complications and mortality in patients with liver disease who undergo cardiac surgery and provide recommendations for the perioperative management.

Cirrosis hepática o falla hepática crónica agudizada: definición y clasificación

La cirrosis se considera el estadio crónico e irreversible de la lesión hepática. Su etiología es diversa y abarca causas como las infecciones víricas, tóxicos como el alcohol, medicamentos, patologías autoinmunes y otras. La descompensación de la cirrosis hepática es consecuencia de cambios fisiopatológicos que se dan con el tiempo como ascitis, peritonitis bacteriana espontánea, hemorragia del tubo digestivo, síndrome hepatorrenal, encefalopatía hepática o hipertensión portopulmonar, mientras que la falla hepática crónica agudizada debe considerarse como una entidad que debe diferenciarse de la anterior, ya que es una falla multiorgánica de curso rápido, por lo regular en pacientes hospitalizados en unidad de cuidado intensivo, a menudo secundaria a desencadenantes como estados de choque. El clínico debe identificarlas para su abordaje y evaluación. El método actual adecuado para estadificar esta entidad es el puntaje CLIFF SOFA, que evalúa la mortalidad a 28 y 90 días, permitiendo intervenciones adecuadas en cada caso.

Preoperative MELD score predicts mortality and adverse outcomes following radical cystectomy: analysis of American College of Surgeons National Surgical Quality Improvement Program

Background

The model for end-stage liver disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures.

Objectives

We aimed to correlate a high preoperative MELD score with adverse 30-day postoperative complications following radical cystectomy.

Design and Methods

Patients who underwent elective, non-emergency radical cystectomy were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2017. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were 30-day postoperative mortality, morbidity, and length of hospital stay following radical cystectomy. For further sensitivity analysis, propensity score matching was used to yield a total of 1387 matched pairs and primary outcomes were also assessed in the matched cohort.

Results

Compared with patients with a MELD < 10, those with MELD ⩾ 10 had significantly higher rates of mortality [odds ratio (OR) = 1.71, p = 0.004], major complications (OR = 1.42, p < 0.001), and prolonged hospital stay (OR = 1.29, p < 0.001) on multivariate analysis. Following risk-adjustment for race, propensity-matched groups revealed that patients with MELD score ⩾ 10 were significantly associated with higher mortality (OR = 1.85, p = 0.008), major complications (OR = 1.34, p < 0.001), yet similar length of hospital stay (OR = 1.17, p = 0.072).

Conclusion

MELD score ⩾ 10 is associated with higher mortality and morbidity in patients undergoing radical cystectomy compared with lower MELD scores. Risk-stratification using MELD score may assist clinicians in identifying high-risk patients to provide adequate preoperative counseling, optimize perioperative conditions, and even consider nonsurgical alternatives.

A machine learning approach to model for end-stage liver disease score in cardiac surgery

OBJECTIVE

Model for end-stage liver disease (MELD) likely has nonlinear effects on operative outcomes. We use machine learning to evaluate the nonlinear (dependent variable may not correlate one to one with an increased risk in the outcome) relationship between MELD and outcomes of cardiac surgery.

METHODS

Society of Thoracic Surgery indexed elective cardiac operations between 2011 and 2018 were included. MELD was retrospectively calculated. Logistic regression models and an imbalanced random forest classifier were created on operative mortality. Cox regression models and random forest survival models evaluated survival. Variable importance analysis (VIMP) ranked variables by predictive power. Linear and machine-learned models were compared with receiver operator characteristic (ROC) and Brier score.

RESULTS

We included 3872 patients. Operative mortality was 1.7% and 5-year survival was 82.1%. MELD was the fourth largest positive predictor on VIMP analysis for operative long-term survival and the strongest negative predictor for operative mortality. MELD was not a significant predictor for operative mortality or long-term survival in the logistic or Cox regressions. The logistic model ROC area was 0.762, compared to the random forest classifier ROC of 0.674. The Brier score of the random forest survival model was larger than the Cox regression starting at 2 years and continuing throughout the study period. Bootstrap estimation on linear regression demonstrated machine-learned models were superior.

CONCLUSIONS

MELD and mortality are nonlinear. MELD was insignificant in the Cox multivariable regression but was strongly important in the random forest survival model and when using bootstrapping, the superior utility was demonstrated of the machine-learned models.

Impact of preoperative liver dysfunction on outcomes in patients with left ventricular assist devices

OBJECTIVES

We evaluated the impact of preoperative liver function on early and 1-year postoperative outcomes in patients supported with a left ventricular assist device (LVAD) and subsequent evolution of liver function markers.

METHODS

A retrospective multicentre cohort study was conducted, including all patients undergoing continuous-flow LVAD implantation. The Model for End-stage Liver Disease (MELD) score was used to define liver dysfunction.

RESULTS

Overall, 290 patients with an LVAD [78% HeartMate II, 15% HVAD and 7% HeartMate 3, mean age 55 (18), 76% men] were included. Over 40 000 measurements of liver function markers were collected over a 1-year period. A receiver operating characteristic curve analysis for the 1-year mortality rate identified the optimal cut-off value of 12.6 for the MELD score. Therefore, the cohort was dichotomized into patients with an MELD score of less than or greater than 12.6. The early (90-day) survival rates in patients with and without liver dysfunction were 76% and 91% (P = 0.002) and 65% and 90% at 1 year, respectively (P < 0.001). Furthermore, patients with preoperative liver dysfunction had more embolic events and more re-explorations. At the 1-year follow-up, liver function markers showed an overall improvement in the majority of patients, with or without pre-LVAD liver dysfunction.

CONCLUSIONS

Preoperative liver dysfunction is associated with higher early 90-day and 1-year mortality rates after LVAD implantation. Furthermore, liver function improved in both patient groups. It has become imperative to optimize the selection criteria for possible LVAD candidates, since those who survive the first year show excellent recovery of their liver markers.

Predicting Operative Outcomes in Patients with Liver Disease: Albumin-Bilirubin Score vs Model for End-Stage Liver Disease-Sodium Score

BACKGROUND

The albumin-bilirubin score (ALBI) has recently been shown to have increased accuracy in predicting post-hepatectomy liver failure and mortality compared with the Model for End-Stage Liver Disease (MELD). However, the use of ALBI as a predictor of postoperative mortality for other surgical procedures has not been analyzed. The aim of this study was to measure the predictive power of ALBI compared with MELD-sodium (MELD-Na) across a wide range of surgical procedures.

STUDY DESIGN

Patients undergoing cardiac, pulmonary, esophageal, gastric, gallbladder, pancreatic, splenic, appendix, colorectal, adrenal, renal, hernia, and aortic operations were identified in the 2015-2018 American College of Surgeons NSQIP database. Patients with missing laboratory data were excluded. Univariable analysis and receiver operator characteristic curves were performed for 30-day mortality and morbidity. Areas under the curves were calculated to validate and compare the predictive abilities of ALBI and MELD-Na.

RESULTS

Of 258,658 patients, the distribution of ALBI grades 1, 2, 3 were 51%, 42%, and 7%, respectively. Median MELD-Na was 7.50 (interquartile range 6.43 to 9.43). Overall 30-day mortality rate was 2.7% and overall morbidity was 28.6%. Increasing ALBI grade was significantly associated with mortality (ALBI grade 2: odds ratio [OR] 5.24; p < 0.001; ALBI grade 3: OR 25.6; p < 0.001) and morbidity (ALBI grade 2: OR 2.15; p < 0.001; ALBI grade 3: OR 6.12; p < 0.001). On receiver operator characteristic analysis, ALBI outperformed MELD-Na with increased accuracy in several operations.

CONCLUSIONS

ALBI score predicts mortality and morbidity across a wide spectrum of surgical procedures. When compared with MELD-Na, ALBI more accurately predicts outcomes in patients undergoing pulmonary, elective colorectal, and adrenal operations.

Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial)

Purpose

To establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites.

Methods

Patients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate.

Results

Thirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI − 0.87 to 24.77; MCS 10.04, 95% CI − 2.78 to 22.86).

Conclusion

This trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints.

Trial registration

Clinicaltrials.gov, NCT01421550, on 23 August 2011.

Does Preoperative MELD Score Predict Adverse Outcomes Following Pancreatic Resection: an ACS NSQIP Analysis

BACKGROUND

Higher MELD scores correlate with adverse operative outcomes regardless of the presence of liver disease, but their impact on pancreatectomy outcomes remains undefined. We aimed to compare 30-day adverse postoperative outcomes of patients undergoing elective pancreatectomy stratified by MELD score.

METHODS

Elective pancreatoduodenectomies (PDs) and distal pancreatectomies (DPs) were identified from the 2014-2016 ACS NSQIP Procedure Targeted Pancreatectomy Participant Use Data Files. Outcomes examined included mortality, cardiopulmonary complications, prolonged postoperative length-of-stay, discharge not-to-home, transfusion, POPF, CR-POPF, any complication, and serious complication. Outcomes were compared between MELD score strata (< 11 vs. ≥ 11) as established by the United Network for Organ Sharing (UNOS). Multivariable logistic regression models were constructed to examine the risk-adjusted impact of MELD score on outcomes.

RESULTS

A total of 7580 PDs and 3295 DPs had evaluable MELD scores. Of these, 1701 PDs and 223 DPs had a MELD score ≥ 11. PDs with MELD ≥ 11 exhibited higher risk for mortality (OR = 2.07, p < 0.001), discharge not-to-home (OR = 1.26, p = 0.005), and transfusion (OR = 1.7, p < 0.001). DP patients with MELD ≥ 11 demonstrated prolonged LOS (OR = 1.75, p < 0.001), discharge not-to-home (OR = 1.83, p = 0.01), and transfusion (OR = 2.78, p < 0.001). In PD, MELD ≥ 11 was independently predictive of 30-day mortality (OR = 1.69, p = 0.007) and transfusion (OR = 1.55, p < 0.001). In DP, MELD ≥ 11 was independently predictive of prolonged LOS (OR = 1.42, p = 0.026) and transfusion (OR = 2.3, p < 0.001).

CONCLUSION

A MELD score ≥ 11 is associated with a near twofold increase in the odds of mortality following pancreatoduodenectomy. The MELD score is an objective assessment that aids in risk-stratifying patients undergoing pancreatectomy.

Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

BACKGROUND AND AIMS

Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures.

METHODS

We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review.

RESULTS

Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate.

CONCLUSIONS

Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.

The impact of cirrhosis in patients undergoing cardiac surgery: a retrospective observational cohort study

PURPOSE

Patients with cirrhosis and concomitant coronary/valvular heart disease present a clinical dilemma. The therapeutic outcome of major cardiac surgery is significantly poorer in patients with cirrhosis compared with patients without cirrhosis. To address this, we aimed to identify associations between the severity of cirrhosis and post-cardiac surgical outcomes.

METHODS

A historical cohort analysis of patients undergoing cardiac surgery at the University of Alberta Hospital from January 2004 to December 2014 was used to identify and propensity score-match 60 patients with cirrhosis to 310 patients without cirrhosis. The relationships between cirrhosis and i) mortality, ii) postoperative complications, and iii) requirement of healthcare resources were evaluated.

RESULTS

Ten-year mortality was significantly higher in cirrhotic patients compared with propensity score-matched non-cirrhotic patients (40% vs 20%; relative risk [RR], 2.0; 95% confidence interval [CI], 1.3 to 2.9; P = 0.001). Cirrhotic patients had more complications (63% vs 48%; RR, 1.3; 95% CI, 1.05 to 1.7; P = 0.02), longer median [interquartile range (IQR)] intensive care unit stays (5 [3-11] vs 2 [1-4] days; P < 0.001), time on mechanical ventilation (median [IQR] 2 [1-5] vs 1 [0.5-1.2] days; P < 0.001) and more frequently required renal replacement therapy (15% vs 6%; RR, 2.5; 95% CI, 1.2 to 5.2; P = 0.02) postoperatively. After adjusting for other covariates, presence of cirrhosis (adjusted odds ratio, 2.2; 95% CI, 1.1 to 4.1) and intraoperative transfusion (adjusted odds ratio, 3.2; 95% CI, 1.6 to 6.3) were independently associated with increased mortality.

CONCLUSION

Despite having low median model for end-stage liver disease scores, this small series of cirrhotic patients undergoing cardiac surgery had significantly higher mortality rates and required more organ support postoperatively than propensity score-matched non-cirrhotic patients. Impact de la cirrhose chez les patients subissant une chirurgie cardiaque : une étude de cohorte observationnelle et rétrospective.

Model for End-Stage Liver Disease Score Independently Predicts Mortality in Cardiac Surgery

BACKGROUND

Although liver disease increases surgical risk, it is not considered in The Society for Thoracic Surgeons (STS) risk calculator. This study assessed the impact of Model for End-Stage Liver Disease (MELD) on outcomes after cardiac surgical procedures and the additional predictive value of MELD in the STS risk model.

METHODS

Deidentified records of 21,272 patients were extracted from a regional STS database. Inclusion criteria were any cardiac operation with a risk score available (2011-2016). Exclusion criteria included missing MELD (n = 2,895) or preoperative anticoagulation (n = 144). Patients were stratified into three categories, MELD < 9 (low), MELD 9 to 15 (moderate), and MELD > 15 (high). Univariate and multivariate logistic regression assessed risk-adjusted associations between MELD and operative outcomes.

RESULTS

Increasing MELD scores were associated with greater comorbid disease, mitral operation, prior cardiac operation, and higher STS-predicted risk of mortality (1.1%, 2.3%, and 6.0% by MELD category; p < 0.0001). The operative mortality rate increased with increasing MELD score (1.6%, 3.9%, and 8.4%; p < 0.0001). By logistic regression MELD score was an independent predictor of operative mortality (odds ratio, 1.03 per MELD score point; p < 0.0001) as were the components total bilirubin (odds ratio, 1.22 per mg/dL; p = 0.002) and international normalized ratio (odds ratio, 1.40 per unit; p < 0.0001). Finally, MELD score was independently associated with STS major morbidity and the component complications renal failure and stroke.

CONCLUSIONS

Increasing MELD score, international normalized ratio, and bilirubin all independently increase risk of operative mortality. Because high rates of missing data currently limit utilization of MELD, efforts to simplify and improve data collection would help improve future risk models.

Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis

Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years.

The aspartate transaminase/alanine transaminase (DeRitis) ratio predicts mid-term mortality and renal and respiratory dysfunction after left ventricular assist device implantation

OBJECTIVES

Preoperative liver dysfunction is a well-known risk factor for adverse events after major surgery. However, there is only little data regarding the precise role of the Model of End-Stage Liver Disease (MELD) score and the De Ritis ratio (DRR, alanine transaminase/aspartate aminotransferase) as a predictor for outcome after left ventricular assist device (LVAD) implantation.

METHODS

A retrospective analysis of all patients undergoing LVAD implantation at our institution between January 2012 and August 2014 was performed. The primary outcome was survival at 180 days after surgery.

RESULTS

During the observation period, 63 patients underwent LVAD implantation (mean age 59.9 ± 8.3 years, 50% male). Mean preoperative ejection fraction was 16.3 ± 7.7, 13 patients required preoperative renal replacement therapy and 9 patients were on extracorporeal life support. Mean Interagency Registry for Mechanically Assisted Circulatory Support level was 2.8 ± 1.3, mean preoperative MELD was 12.7 ± 7.2, mean preoperative DRR was 2.01 ± 4.4. Aspartate aminotransferase (102 ± 220.8 vs 57.8 ± 123.4 U/l, P = 0.041), MELD score (16.1 ± 8.8 vs 11.4 ± 6.1, P = 0.017) and DRR (4.2 ± 7.8 vs 1.1 ± 1.1, P = 0.001) were significantly higher in non-survivors than in survivors after 180 days. Using logistic regression analyses, a DRR >1.37 was an independent predictor for 30-day mortality [odds ratio (OR) 4.5] and 180-day mortality (OR 4.1). In addition, the DRR was associated with postoperative acute kidney injury with need for renal replacement therapy (OR 4.2) and prolonged postoperative ventilation time >72 h (OR 3.8). Using receiver operator characteristics analyses, DRR showed a sensitivity of 0.80 and a specificity of 0.81 (area under the curve 0.834, cut-off 1.37) for 180-day mortality.

CONCLUSIONS

The DRR is predictive of early and mid-term mortality as well as relevant morbidities in patients undergoing LVAD implantation. Therefore, the DRR should be considered within the preoperative risk stratification and patient selection for LVAD implantation.

Combined value of left ventricular ejection fraction and the Model for End-Stage Liver Disease (MELD) score for predicting mortality in patients with acute coronary syndrome who were undergoing percutaneous coronary intervention

Background

The purpose of the study was to investigate whether the addition of left ventricular ejection fraction (LVEF) to the MELD score enhances the prediction of mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

Methods

This retrospective study analyzed 846 consecutive patients with ACS undergoing PCI who were not receiving previous anticoagulant therapy. The patients were grouped as survivors or non-survivors. The MELD score and LVEF were calculated in all patients. The primary end point was all-cause death during the median follow-up of 28 months.

Results

During the follow-up, there were 183 deaths (21.6%). MELD score was significantly higher in non-survivors than survivors (10.1 ± 4.4 vs 7.8 ± 2.4, p <  0.001). LVEF was lower in non-survivors compared with survivors (41.3 ± 11.8% vs. 47.5 ± 10.0%, p <  0.001). In multivariate analysis, both MELD score and LVEF were independent predictors of total mortality. (HR: 1.116, 95%CI: 1.069–1.164, p <  0.001; HR: 0.972, 95%CI: 0.958–0.986, p <  0.001, respectively). The addition of LVEF to MELD score was associated with significant improvement in predicting mortality compared with the MELD score alone (AUC:0.733 vs 0.690, p <  0.05). Also, the combining LVEF with MELD score improved the reclassification (NRI:24.6%, p <  0.001) and integrated discrimination (IDI:0.045, p <  0.001) of patients compared with MELD score alone.

Conclusions

Our study demonstrated that the combining LVEF with MELD score may be useful to predict long-term survival in patients with ACS who were undergoing PCI.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0782-8) contains supplementary material, which is available to authorized users.

Analysis of the MELD Score Impact in the Outcome of Endovascular Portal Vein Reconstruction

INTRODUCTION

Endovascular therapy represents a less invasive alternative to open surgery for reconstruction of the portal vein (PV) and the spleno-mesenteric venous confluence to treat Portal hypertension. The objective of this study is to determine if the Model for End-Stage Liver Disease (MELD) score is a useful method to evaluate the risk of morbidity and mortality during endovascular approaches.

MATERIAL AND METHODS

Patients that underwent endovascular reconstruction of the PV or spleno-mesenteric confluence were identified retrospectively. Data were collected from November 2011 to August 2016. The MELD score was calculated using international normalized ratio, serum billirubin and creatinine. Patients were grouped into moderate (≤ 15) and high (> 15) MELD. Associations of the MELD score on the postprocedural morbidity, mortality and vessels patency were assessed by two-sided Fisher's exact test.

RESULTS

Seventeen patients were identified; MELD score distribution was: ≤ 15 in 10 patients (59%) and > 15 in 7 (41%). Even distribution of severe PV thrombosis was treated in both groups, performing predominately jugular access in the high MELD score group (OR 0.10; 95%; CI 0.014-0.89; p = 0.052) in contrast to a percutaneous transhepatic access in the moderate MELD score group. Analysis comparing moderate and high MELD scores was not able to demonstrate differences in mortality, morbidity or patency rates.

CONCLUSION

MELD score did not prove to be a useful method to evaluate risk of morbidity and mortality; however a high score should not contraindicate endovascular approaches. In our experience a high technical success, good patency rates and low complication rates were observed.

The Role of the Model of End-Stage Liver Disease Score in Predicting Outcomes of Carotid Endarterectomy

Objectives:

The Model of End-Stage Liver Disease (MELD) score has been traditionally utilized to prioritize for liver transplantation; however, recent literature has shown its value in predicting surgical outcomes for patients with hepatic dysfunction. The benefit of carotid endarterectomy in asymptomatic patients is dependent on low perioperative morbidity. Our objective was to use MELD score to predict outcomes in asymptomatic patients undergoing carotid endarterectomy.

Methods:

Patients undergoing carotid endarterectomy were identified in the National Surgical Quality Improvement Program data sets from 2005 to 2012. The Model of End-Stage Liver Disease score was calculated using serum bilirubin, creatinine, and the international normalized ratio (INR). Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The effect of the MELD score on postoperative morbidity and mortality was assessed by multivariable logistic and gamma regressions and propensity matching.

Results:

There were 7966 patients with asymptomatic carotid endarterectomy identified. The majority 5556 (70%) had a low MELD score, 1952 (25%) had a moderate MELD score, and 458 (5%) had a high MELD score. High MELD score was independently predictive of postoperative death, increased length of stay, need for transfusion, pulmonary complications, and a statistical trend toward increased cardiac arrest/myocardial infarction. The Model of End-Stage Liver Disease score did not affect postoperative stroke, wound complications, or operative time.

Conclusion:

High MELD score places asymptomatic patients undergoing carotid endarterectomy at a higher risk of adverse outcomes in the 30 days following surgery. This provides further empirical evidence for risk stratification when considering treatment for these patients. Outcomes of medical management or carotid stenting should be investigated in high-risk patients.

The role of Model for End-Stage Liver Disease (MELD) score in predicting outcomes for lower extremity bypass

OBJECTIVE

The Model for End-Stage Liver Disease (MELD) score has traditionally been used to prioritize liver transplantation. However, its use has been extended to predict overall and postoperative outcomes in patients with hepatic and renal dysfunction. Our objective was to use the MELD score to predict outcomes in patients undergoing lower extremity bypass.

METHODS

Patients undergoing infrainguinal bypass were identified in the American College of Surgeons National Surgical Quality Improvement Program data sets from 2005 to 2012. The MELD score was calculated using serum bilirubin and creatinine values and the international normalized ratio. Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The associations of the MELD score on postoperative morbidity and mortality were assessed by multivariable logistic and gamma regressions and by propensity matching.

RESULTS

There were 5967 patients who underwent infrainguinal bypass with the following MELD score distribution: <9, 3795 (64%); 9 to 14, 1819 (30%); and 15+, 353 (6%). Matched analysis in comparing low, moderate, and high MELD scores showed a higher risk for cardiac complications (2.8% vs 3.2% vs 5.4%; P < .001), bleeding complications (9.3% vs 11.1% vs 13.9%; P = .048), and increased postoperative length of stay (median [range], 5 [0-93] vs 6 [0-73] vs 6 [0-86]; P < .001). The MELD score had no association with early bypass failure, wound complications, or operative time. Moderate and high MELD scores were independent predictors of postoperative myocardial infarction/cardiac arrest (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001; and OR, 4.1; 95% CI, 2.3-7.3; P < .01), bleeding complications (OR, 1.3; 95% CI, 1.1-1.6; P < .01; and OR, 1.8; 95% CI, 1.3-2.5; P < .01), return to the operating room (OR, 1.3; 95% CI, 1.1-1.5; P < .01; and OR, 1.4; 95% CI, 1.03-1.8; P = .03), extended postoperative length of stay (means ratio, 1.2; 95% CI, 1.1-1.2; P < .01; and means ratio, 1.2; 95% CI, 1.2-1.3; P < .01), and perioperative mortality (OR, 1.6; 95% CI, 1.02-2.5; P = .04; and OR, 2.9; 95% CI, 1.6-5.4; P = .01), respectively. Propensity matching between low, moderate, and high MELD score groups confirmed an increased risk of postoperative myocardial infarction/cardiac arrest (P < .01), bleeding complications (P = .05), and extended postoperative length of stay (P < .01) with a trend toward increased mortality and return to operating room.

CONCLUSIONS

An elevated MELD score places patients undergoing infrainguinal bypass at higher risk of perioperative morbidity and mortality. This provides an evidence base for risk stratification and informed consent for these patients. Alternative treatment may be considered in these patients; however, the overall morbidity and mortality rates may still be acceptable, even in high-risk patients.

Influence of cirrhosis in cardiac surgery outcomes

Liver cirrhosis has evolved an important risk factor for cardiac surgery due to the higher morbidity and mortality that these patients may suffer compared with general cardiac surgery population. The presence of contributing factors for a poor outcome, such as coagulopathy, a poor nutritional status, an adaptive immune dysfunction, a degree of cirrhotic cardiomyopathy, and a degree of renal and pulmonary dysfunction, have to be taken into account for surgical evaluation when cardiac surgery is needed, together with the degree of liver disease and its primary complications. The associated pathophysiological characteristics that liver cirrhosis represents have a great influence in the development of complications during cardiac surgery and the postoperative course. Despite the population of cirrhotic patients who are referred for cardiac surgery is small and recommendations come from small series, since liver cirrhotic patients have increased their chance of survival in the last 20 years due to the advances in their medical care, which includes liver transplantation, they have been increasingly considered for cardiac surgery. Indeed, there is an expected rise of cirrhotic patients within the cardiac surgical population due to the increasing rates of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, especially in western countries. In consequence, a more specific approach is needed in the assessment of care of these patients if we want to improve their management. In this article, we review the pathophysiology and outcome prediction of cirrhotic patients who underwent cardiac surgery.

[Lung cancer surgery and cirrhosis]

INTRODUCTION

Lung cancer is the leading cause of death by cancer and cirrhosis is the fourteenth, all causes included. Surgery increases postoperative risks in cirrhotic patients. Our purpose was to analyze this point in lung cancer surgery.

METHODS

We collected, among 7162 patients, the data concerning those operated for lung cancer (n=6105) and compared patients with hepatic disease (n=448) to those presenting other medical disorder (n=2587). We analyzed cirrhotic patients' characteristics (n=49).

RESULTS

Five-year survival of patients with hepatic disease was lower (n=5657/6105): 35.3% versus 43.8% for patients with no hepatic disease, P=0.0021. Survival of cirrhotic patients was not statistically different from the one of patients with other hepatic disorder, but none survived beyond 10 years (0% versus 26.4%). Surgery in cirrhotic patients consisted in one explorative thoracotomy, three wedges resections, two segmentectomies, 33 lobectomies and 10 pneumonectomies. Postoperative mortality (8.2%; 4/49) was not different for patients without hepatic disease (4.2%; 239/5657) (P=0.32), as well as the rate of complications (40.8%; 20/49 and 24.8%; 1404/5657, P=0.11). Only one postoperative death was associated to a hepatic failure. Multivariate analysis pointed age, histological subtype of the tumour and stage of disease as independent prognosis factors.

CONCLUSION

When cirrhosis is well compensated, surgical resection of lung cancer can be performed with acceptable postoperative morbidity and satisfactory rates of survival. Progressive potential of this disease is worse after five years.