Prognostic Value of Hepatorenal Function By Modified Model for End-stage Liver Disease (MELD) Score in Patients Undergoing Tricuspid Annuloplasty

Off-Pump Reduces Risk of Coronary Bypass Grafting in Patients with High MELD-XI Score

BACKGROUND

 This study aimed to assess the influence of the model of end-stage liver disease without International Normalized Ratio (INR) (MELD-XI) score on outcomes after elective coronary artery bypass surgery (CABG) without (Off-Pump) or with (On-Pump) cardiopulmonary bypass.

METHODS

 We calculated MELD-XI (5.11 × ln serum bilirubin + 11.76 × ln serum creatinine in + 9.44) for 3,535 consecutive patients having undergone elective CABG between 2009 and 2020. A MELD-XI threshold was determined using the Youden Index based on receiver operating characteristics. Propensity score matching and logistic regression was performed to identify risk factors for inhospital mortality and Major Adverse Cardiac and Cerebrovascular Event (MACCE).

RESULTS

 Patients were 68 ± 10 years old (76% male). Average MELD-XI was 10.9 ± 3.25. The MELD-XI threshold was 11. Patients below this threshold had somewhat lower EuroSCORE II than those above (3.5 ± 4 vs. 4.1 ± 4.7, p < 0.01), but mortality was almost four times higher above the threshold (below 1.5% vs. above 6.2%, p < 0.001). Two-thirds of patients received Off-Pump CABG. There was a trend towards higher risk in Off-Pump patients. Mortality was numerically but not statistically different to On-Pump below the MELD XI threshold (1.3 vs. 2.2%, p = 0.34) and was significantly lower above the threshold (4.9 vs. 8.9%, p < 0.02). Off-Pump above the threshold was also associated with less low-output syndrome and fewer strokes. Equalizing baseline differences by propensity matching verified the significant mortality difference above the threshold. Multivariable regression analysis revealed MELD-XI, On-Pump, atrial fibrillation, and the De Ritis quotient (Aspartate aminotransferase (ASAT)/Alanine Aminotransferase (ALAT)) as independent predictors of mortality.

CONCLUSION

 Elective CABG patients with elevated MELD-XI scores are at increased risk for perioperative mortality and morbidity. This risk can be significantly mitigated by performing CABG Off-Pump.

Tricuspid Regurgitation in Congestive "End-Organ" Failure: Outline of an Opportunity

Tricuspid regurgitation (TR) is a progressive disease that can be addressed only partially by medical therapy. Progression of TR is associated with worsening end-organ function and worse survival, yet tricuspid valve interventions are usually only performed in advanced stages. Recent evidence suggests a pivotal role for TR and pulsatile venous congestion in the pathophysiology of renal and hepatic dysfunction. This critical knowledge has provided the opportunity to optimally define the appropriate timing of transcatheter tricuspid valve interventions, integrating concurrent or impending functional consequences with severity of TR.

Assessment of cardio-renal-hepatic function in patients with valvular heart disease: a multi-biomarker approach-the cardio-renal-hepatic score

BACKGROUND

Valvular heart disease (VHD) can cause damage to extra-cardiac organs, and lead to multi-organ dysfunction. However, little is known about the cardio-renal-hepatic co-dysfunction, as well as its prognostic implications in patients with VHD. The study sought to develop a multi-biomarker index to assess heart, kidney, and liver function in an integrative fashion, and investigate the prognostic role of cardio-renal-hepatic function in VHD.

METHODS

Using a large, contemporary, prospective cohort of 6004 patients with VHD, the study developed a multi-biomarker score for predicting all-cause mortality based on biomarkers reflecting heart, kidney, and liver function (N-terminal pro-B-type natriuretic peptide [NT-proBNP], creatinine, and albumin). The score was externally validated in another contemporary, prospective cohort of 3156 patients with VHD.

RESULTS

During a median follow up of 731 (704-748) days, 594 (9.9%) deaths occurred. Increasing levels of NT-proBNP, creatinine, and albumin were independently and monotonically associated with mortality, and a weighted multi-biomarker index, named the cardio-renal-hepatic (CRH) score, was developed based on Cox regression coefficients of these biomarkers. The CRH score was a strong and independent predictor of mortality, with 1-point increase carrying over two times of mortality risk (overall adjusted hazard ratio [95% confidence interval]: 2.095 [1.891-2.320], P < 0.001). The score provided complementary prognostic information beyond conventional risk factors (C index: 0.78 vs 0.81; overall net reclassification improvement index [95% confidence interval]: 0.255 [0.204-0.299]; likelihood ratio test P < 0.001), and was identified as the most important predictor of mortality by the proportion of explainable log-likelihood ratio χ² statistics, the best subset analysis, as well as the random survival forest analysis in most types of VHD. The predictive performance of the score was also demonstrated in patients under conservative treatment, with normal left ventricular systolic function, or with primary VHD. It achieved satisfactory discrimination (C index: 0.78 and 0.72) and calibration in both derivation and validation cohorts.

CONCLUSIONS

A multi-biomarker index was developed to assess cardio-renal-hepatic function in patients with VHD. The cardio-renal-hepatic co-dysfunction is a powerful predictor of mortality and should be considered in clinical management decisions.

Prognostic value of the liver fibrosis marker fibrosis-5 index in patients with severe isolated tricuspid regurgitation: comparison with fibrosis-4 index

The fibrosis-4 index (FIB4), a liver fibrosis maker, has been shown to be associated with the prognosis in patients with severe isolated tricuspid regurgitation (TR). Recent study showed that the fibrosis-5 index (FIB5), which was calculated by albumin, alkaline phosphatase, aspartate transaminase, alanine aminotransferase and platelet count, had better prognostic value than FIB4 in patients with heart failure. The aim of this study was to evaluate the usefulness of FIB5 index for predicting prognosis in patients with severe isolated TR and compare the prognostic value between the FIB4 and the FIB5 in those patients. This was a dual-center, retrospective study. 113 consecutive outpatients with severe isolated TR (mean age, 65.8 years; 47.8% male) were analyzed. Major adverse cardiovascular events (MACEs) were defined as the composite of cardiovascular death, hospitalization for heart failure, myocardial infarction, and stroke. During a median follow-up of 3.0 years, 41 MACEs occurred. Patients with MACEs had a lower the FIB5 than patients without MACEs. The multivariate Cox analysis revealed that the FIB5 < -4.30 was significantly associated with higher incidence of MACEs after adjusted by confounding factors. Receiver-operating characteristic curve analyses showed that prognostic values did not differ between the FIB5 and the FIB4 in whole patients and in patients aged ≥ 70 years; while, in patients aged < 70 years, the FIB5 had better prognostic value than the FIB4. The FIB5 may be a useful predictor of MACEs in patients with severe isolated TR.

A streamlined, machine learning-derived approach to risk-stratification in heart failure patients with secondary tricuspid regurgitation

AIMS

Secondary tricuspid regurgitation (sTR) is the most frequent valvular heart disease and has a significant impact on mortality. A high burden of comorbidities often worsens the already dismal prognosis of sTR, while tricuspid interventions remain underused and initiated too late. The aim was to examine the most powerful predictors of all-cause mortality in moderate and severe sTR using machine learning techniques and to provide a streamlined approach to risk-stratification using readily available clinical, echocardiographic and laboratory parameters.

METHODS AND RESULTS

This large-scale, long-term observational study included 3359 moderate and 1509 severe sTR patients encompassing the entire heart failure spectrum (preserved, mid-range and reduced ejection fraction). A random survival forest was applied to investigate the most important predictors and group patients according to their number of adverse features.The identified predictors and thresholds, that were associated with significantly worse mortality were lower glomerular filtration rate (<60 mL/min/1.73m2), higher NT-proBNP, increased high sensitivity C-reactive protein, serum albumin < 40 g/L and hemoglobin < 13 g/dL. Additionally, grouping patients according to the number of adverse features yielded important prognostic information, as patients with 4 or 5 adverse features had a fourfold risk increase in moderate sTR [4.81(3.56-6.50) HR 95%CI, P < 0.001] and fivefold risk increase in severe sTR [5.33 (3.28-8.66) HR 95%CI, P < 0.001].

CONCLUSION

This study presents a streamlined, machine learning-derived and internally validated approach to risk-stratification in patients with moderate and severe sTR, that adds important prognostic information to aid clinical-decision-making.

Prognostic Value of Different Versions of the Model for End-Stage Liver Disease Score in Patients Undergoing Percutaneous Coronary Intervention

The model for end-stage liver disease (MELD) score, which can reflect liver and renal function, is associated with poor prognosis. However, the prognostic performance of the modified MELD score in patients undergoing elective percutaneous coronary intervention (PCI) has not been fully evaluated and compared. This study retrospectively enrolled 5324 patients. During a median follow-up of 2.85 years, 412 patients died. Time-dependent receiver operating characteristic curves at 3 years indicated that the MELD including albumin (MELD-Albumin) score had the highest prognostic performance (AUC = .721) than the MELD score (AUC = .630), the MELD excluding the international normalized ratio (MELD-XI) score (AUC = .606), and the MELD including sodium (MELD-Na) score (AUC = .656) (all P < .001). The MELD-Albumin score, the MELD score, and the MELD-Na score were independent predictors of long-term mortality; however, the MELD-XI score was not when treated as a categorical variable (P = .254). Adding the MELD-Albumin score to the model of clinical risk factors could improve the prognostic performance. For the subgroup analysis, the association between the MELD-Albumin score and long-term mortality was more pronounced in patients ≤75 years (interaction P value = .005). The MELD-Albumin score showed the strongest prognostic performance than the other versions of the MELD score in patients undergoing elective PCI.

Long-Term Clinical Outcomes in Patients With Severe Tricuspid Regurgitation

Background The natural history and optimal interventional timing in patients with isolated severe tricuspid regurgitation (TR) have not been well studied. This study aimed to investigate long-term clinical outcomes and risk factors associated with poor prognosis in patients with isolated severe TR. Methods and Results Consecutive transthoracic echocardiographic examinations in 2877 patients with isolated severe TR were retrospectively reviewed. Patients with significant left-sided valve disease or repeated examinations were excluded. Primary outcome was defined as a composite of all-cause death and hospitalization for heart failure. Among the 613 enrolled patients (mean age, 74±13 years; men, 38%), 141 died, and 62 were hospitalized for heart failure during the median follow-up period of 26.5 (interquartile range, 6.0-57.9) months. The 5-year event-free rate was 60.1%. TR pressure gradient (adjusted hazard ratio [HR], 1.03 [95% CI, 1.01-1.04]), blood urea nitrogen (adjusted HR, 1.02 [95% CI, 1.01-1.04]), left atrial volume index (adjusted HR, 1.01 [95% CI, 1.002-1.02]), and serum albumin (adjusted HR, 0.56 [95% CI, 0.36-0.95]) were identified as independent predictors of adverse events. A risk model based on the 4 clinical factors that included pulmonary hypertension (TR pressure gradient >40 mm Hg), elevated blood urea nitrogen levels (>25 mg/dL), decreased albumin levels (<3.7 g/dL), and left atrial enlargement (left atrial volume index <34 mL/m²) revealed a graded increase in the risk of adverse events (P<0.001). Conclusions The prognosis of isolated severe TR is not always favorable. Careful attention should be paid to patients with concomitant risk factors, such as pulmonary hypertension, elevated blood urea nitrogen levels, decreased albumin levels, and left atrial enlargement.

Prognostic value of the dynamic hepatorenal function on intermediate-term mortality in TAVI patients with survival to discharge

BACKGROUND

Renal and liver dysfunctions are risk factors for mortality in patients with severe aortic stenosis (AS). Transcatheter aortic valve implantation (TAVI) has the potential to break the vicious cycle between AS and hepatorenal dysfunction by relieving aortic valve obstruction.

HYPOTHESIS

A part of patients can derive hepatorenal function improvement from TAVI, and this noncardiac benefit improves the intermediate-term outcomes.

METHODS

We developed this retrospective cohort study in 439 consecutive patients undergoing TAVI and described the dynamic hepatorenal function assessed by model for end-stage liver disease model for end-stage liver disease (MELD)-XI score in subgroups. The endpoint was 2-year all-cause mortality.

RESULTS

Receiver-operating characteristic analysis showed that the baseline MELD-XI score of 10.71 was the cutoff point. A high MELD-XI score (>10.71) at baseline was an independent predictor of the 2-year mortality hazard ratio (HR: 2.65 [1.29-5.47], p = .008). After TAVI, patients with irreversible high MELD-XI scores had a higher risk of 2-year mortality than patients who improved from high to low MELD-XI scores (HR: 2.50 [1.06-5.91], p = .03). Factors associated with reversible MELD-XI scores improvement were low baseline MELD-XI scores (≤12.00, odds ratio [OR]: 2.02 [1.04-3.94], p = .04), high aortic valve peak velocity (≥5 m/s, OR: 2.17 [1.11-4.24], p = .02), and low body mass index (≤25 kg/m² , OR: 2.73 [1.25-5.98], p = .01).

CONCLUSION

High MELD-XI score at baseline is an independent predictor for 2-year mortality. Patients with hepatorenal function improvement after TAVI have better outcomes. For patients with irreversible hepatorenal dysfunction after TAVI, further optimization of the subsequent treatment after TAVI is needed to improve the outcomes.

Determinants and Prognostic Implications of Hepatorenal Dysfunction in Adults With Congenital Heart Disease

BACKGROUND

There are limited data on the prognostic role of hepatorenal function indices in ambulatory patients with congenital heart disease (CHD). The purpose of this study was to determine the prevalence, risk factors, and prognostic implications of hepatorenal dysfunction, as measured by Model for End-Stage Liver Disease Excluding International Normalised Ratio (MELD-XI) score, in adults with CHD.

METHODS

In this retrospective study of CHD patients with comprehensive metabolic panels (2003-2019), mild/moderate and severe hepatorenal dysfunction was defined as MELD-XI 11-15 and > 15, respectively.

RESULTS

Of 4977 patients, 1376 (28%) had hepatorenal dysfunction (mild/moderate: n = 935 [19%]; severe: n = 441 [9%]). Hepatorenal dysfunction was most common in Fontan/unrepaired single ventricle (46%) and right heart disease (31%). Baseline MELD-XI was associated with all-cause mortality (HR 1.27, CI 1.21-1.33; P < 0.001) after adjustment for age, sex, and congenital heart lesion. In 3864 patients with serial MELD-XI data, there was a temporal increase in MELD-XI, and this was associated with an increased risk of mortality (HR 1.24, CI 1.15-1.36, per unit increase in MELD-XI; P = 0.004), independently from the baseline MELD-XI score. In the subset of 1856 patients that underwent surgical/transcatheter interventions, there was a postoperative reduction in MELD-XI, and this was associated with a lower risk of mortality (HR 0.94, CI 0.90-0.98, per unit decrease in MELD-XI; P = 0.008), independently from the baseline MELD-XI score.

CONCLUSIONS

Hepatorenal dysfunction was common in adults with CHD. Both baseline MELD-XI score and temporal changes in MELD-XI were associated with clinical outcomes, and therefore could be used to monitor therapeutic response to interventions and for deterioration in clinical status.

The Fibrosis-4 Index Predicts Cardiovascular Prognosis in Patients With Severe Isolated Tricuspid Regurgitation

BACKGROUND

The fibrosis-4 (FIB-4) index is used to evaluate liver disease patients. It can also be used to evaluate the prognosis for heart disease patients; however, its ability to determine the prognosis of severe isolated tricuspid regurgitation (TR) patients is unclear. This study aimed to clarify the association between FIB-4 index scores and the cardiovascular prognosis for severe isolated TR patients.Methods and Results: This was a dual-center, retrospective study. From 2011 to 2019, 111 consecutive outpatients with severe isolated TR (mean age, 68.6 years; 53.2% male) were evaluated. Major adverse cardiovascular events (MACEs) were defined as the composite of cardiovascular death, hospitalization for heart failure, myocardial infarction, and stroke. The association between FIB-4 index scores and echocardiography was also evaluated. During a median follow up of 3.0 years, 24 patients were lost to follow up and 40 MACEs occurred. Baseline FIB-4 index scores for patients with MACEs were significantly higher than those for patients without MACEs. A multivariate analysis revealed that FIB-4 index scores are significantly associated with MACEs (hazard ratio, 1.89; 95% confidence interval, 1.01-3.54; P=0.046). A linear regression analysis indicated that FIB-4 index scores were correlated with echocardiographic parameters, including the left atrial volume index and left ventricular end-diastolic diameter.

CONCLUSIONS

The FIB-4 index score may be a useful predictor of MACEs for patients with severe isolated TR.

Prognostic Value of Modified Model for End-Stage Liver Disease Score in Patients Undergoing Isolated Tricuspid Valve Replacement

Objective

Though the prognostic value of the model for end-stage liver disease (MELD) score in tricuspid surgery was confirmed, the unstable international normalized ratio (INR) may affect the evaluation effectiveness of the MELD score for isolated tricuspid valve replacement (ITVR). The aim of the study was to assess the prognostic value of modified MELD for ITVR.

Methods and Results

A total of 152 patients who underwent ITVR were evaluated. The adverse outcome was defined as in-hospital mortality after surgery. The receiver operating characteristic (ROC) curve analysis demonstrated that a modified MELD score with albumin replacing INR (MELD-albumin) score presented well prognostic value [area under the curve (AUC) = 0.731, p = 0.006] for in-hospital mortality. Through Cox regression and further interval validation, the MELD-albumin score was identified as an independent predictor for in-hospital mortality. The optimal cutoff value of MELD-albumin was identified as 8.58 through maximally selected log-rank statistics. In addition, restricted cubic spline analysis demonstrated the linear inverse relationship between MELD-albumin and hazard ratio (HR) for in-hospital mortality. Kaplan–Meier analysis illustrated that in-hospital mortality was increased significantly in the high MELD-albumin (MELD-albumin ≥8.58) group than in the low MELD-albumin group (MELD-albumin <8.58; p < 0.001). Furthermore, high MELD-albumin was associated with lower body mass index (BMI), the incidence of lower extremities edema and moderate drinking history, and the MELD-albumin score was correlated with the value of aspartate transaminase (AST), alanine transaminase (ALT), and albumin. Furthermore, the incidence of renal failure (p = 0.003) and pulmonary infection (p = 0.042) was increased significantly in the high MELD-albumin group.

Conclusion

The MELD-albumin score could provide prognostic value for ITVR. In addition, the MELD-albumin score was useful in risk stratification and patient selection for patients with tricuspid regurgitation (TR) prior to ITVR.

Improvement in hepatic and renal function following isolated heart transplant in adults with congenital heart disease

BACKGROUND

There are limited data about postoperative changes in hepatic and renal function in adults with congenital heart disease (CHD) undergoing isolated heart transplant. The purpose of this study was to assess postoperative changes in hepatic and renal function in this population.

METHODS

Retrospective cohort study of adults with CHD undergoing isolated heart transplant at Mayo Clinic (2003-2019). Global hepatic function was assessed using the model for end-stage liver disease excluding international normalized ratio [MELD-XI]) score; hepatic fibrosis was assessed using the fibrosis-4 (FIB-4) score and aspartate/platelet ratio index (APRI); and renal function was assessed using estimated glomerular filtration rate (GFR). All indices were measured preoperatively and postoperatively (at 6 months, 1 year, 2 years).

RESULTS

Of 40 patients (age 41 ± 8 years) in the study, 35 had complete preoperative and postoperative data. There was a temporal improvement in hepatic and renal indices from preop (MELD-XI 14 ± 5, APRI 0.60 ± 0.23, FIB-4 1.44 ± 0.38, GFR 59 [44-83]) to 6 months postop (MELD-XI 12 ± 6, APRI 0.49 ± 0.17, FIB-4 1.29 ± 0.33, GFR 68 [54-96]) and 1-year postop (MELD-XI 9 ± 3, APRI 0.41 ± 0.16, FIB-4 1.12 ± 0.29, GFR 82 [69-108]), p < 0.05 for all comparisons.

CONCLUSIONS

CHD patients undergoing isolated heart transplant had significant improvement in hepatic and renal function. These data suggests that selected CHD patients may do well with isolated heart transplant despite reduced hepatic and renal function, and hepatic fibrosis preoperatively. More rigorous prospective studies are required to determine the relative outcomes of isolated versus combined heart-liver transplant in this population.

Prognostic Value of Modified Model for End-Stage Liver Disease Scores in Patients With Significant Tricuspid Regurgitation

AIMS

Tricuspid regurgitation (TR) may cause damage to liver and kidney function. The Model for End-Stage Liver Disease excluding international normalized ratio (MELD-XI) and the model with albumin replacing international normalized ratio (MELD-Albumin) scores, which include both liver and kidney function indexes, may predict mortality in patients with TR. The study aimed to analyze the prognostic value of MELD-XI and MELD-Albumin scores in patients with significant TR.

METHODS AND RESULTS

A total of 1825 patients with at least moderate pure native TR from the China Valvular Heart Disease study between April and June 2018, were included in this analysis. The primary outcome was all-cause death within 2 years. Of 1825 patients, 165 (9.0%) died during follow-up. Restricted cubic splines revealed that hazard ratio for death increased monotonically with greater modified MELD scores. The MELD-XI and MELD-Albumin scores, as continuous variables or categorized using thresholds determined by maximally selected rank statistics, were independently associated with 2-year mortality (all adjusted P<0.001). Both scores provided incremental value over prognostic model without hepatorenal indexes (MELD-XI score: net reclassification index [95% confidence interval], 0.237 [0.138-0.323]; MELD-Albumin score: net reclassification index [95% confidence interval], 0.220 [0.122-0.302]). Results were similar in clinically meaningful subgroups, including but not limited to patients under medical treatment and with normal left ventricular ejection fraction. Models including modified MELD scores were established for prognostic evaluation of significant TR.

CONCLUSION

Both MELD-XI and MELD-Albumin scores provided incremental prognostic information, and could play important roles in risk assessment in patients with significant TR.

Concomitant Hepatorenal Dysfunction and Malnutrition in Valvular Heart Surgery: Long‐Term Prognostic Implications for Death and Heart Failure

Background

Strategies to improve long‐term prediction of heart failure and death in valvular surgery are urgently needed because of an increasing number of procedures globally. This study sought to report the prevalence, changes, and prognostic implications of concomitant hepatorenal dysfunction and malnutrition in valvular surgery.

Methods and Results

In 909 patients undergoing valvular surgery, 3 groups were defined based on hepatorenal function (the modified model for end‐stage liver disease excluding international normalized ratio score) and nutritional status (Controlling Nutritional Status score): normal hepatorenal function and nutrition (normal), hepatorenal dysfunction or malnutrition alone (mild), and concomitant hepatorenal dysfunction and malnutrition (severe). Overall, 32%, 46%, and 19% of patients were classified into normal, mild, and severe groups, respectively. Over a 4.1‐year median follow‐up, mild and severe groups incurred a higher risk of mortality (hazard ratio [HR], 3.17 [95% CI, 1.40–7.17] and HR, 9.30 [95% CI, 4.09–21.16], respectively), cardiovascular death (subdistribution HR, 3.29 [95% CI, 1.14–9.52] and subdistribution HR, 9.29 [95% CI, 3.09–27.99]), heart failure hospitalization (subdistribution HR, 2.11 [95% CI, 1.25–3.55] and subdistribution HR, 3.55 [95% CI, 2.04–6.16]), and adverse outcomes (HR, 2.11 [95% CI, 1.25–3.55] and HR, 3.55 [95% CI, 2.04–6.16]). Modified model for end‐stage liver disease excluding international normalized ratio and controlling nutritional status scores improved the predictive ability of European System for Cardiac Operative Risk Evaluation (area under the curve: 0.80 versus 0.73, P<0.001) and Society of Thoracic Surgeons score (area under the curve: 0.79 versus 0.72, P=0.004) for all‐cause mortality. One year following surgery (n=707), patients with persistent concomitant hepatorenal dysfunction and malnutrition (severe) experienced worse outcomes than those without.

Conclusions

Concomitant hepatorenal dysfunction and malnutrition was frequent and strongly linked to heart failure and mortality in valvular surgery.

Comparison of risk scores for predicting outcomes after isolated tricuspid valve surgery

BACKGROUND

Risk models play important roles in stratification and decision-making towards cardiac surgery. Isolated tricuspid valve surgery is a high risk but increasingly performed the operation, however, the performance of risk models has not been externally evaluated in these patients. We compared the prognostic utility of contemporary risk scores for isolated tricuspid valve surgery.

METHODS

Consecutive patients undergoing isolated tricuspid valve surgery at Cleveland Clinic during 2004-2018 were evaluated in this cohort study. EuroSCORE II, Society of Thoracic Surgeon's tricuspid (STS-TVS) score, and the Model for End-stage Liver Disease (MELD) score were retrospectively calculated, and their performance for predicting operative mortality, postoperative complications, and mortality during follow-up was assessed.

RESULTS

Amongst 207 patients studied, the mean age was 54.1 ± 17.9 years, 116 (56.0%) were female, 92 (44.4%) had secondary tricuspid regurgitation, and 151 (72.9%) had a surgical repair. Mean EuroSCORE II, STS-TVS, and MELD scores were 6.3 ± 6.6%, 5.5 ± 6.2%, and 9.8 ± 4.7, respectively. C-statistics (95% confidence intervals) for operative mortality were 0.83 (0.74-0.93) for EuroSCORE II, 0.60 (0.45-0.75) for STS-TVS score, and 0.74 (0.58-0.89) for MELD score, while observed/expected ratios were 0.78 and 0.89 for the first two scores. All three scores were associated with mortality during follow-up and discriminated most postoperative complications.

CONCLUSION

EuroSCORE II was superior to STS-tricuspid score for isolated TVS risk assessment. Although surgical risk scores traditionally underestimated operative mortality after isolated tricuspid valve surgery, they did not in our cohort, reflecting the excellent surgical results. The simple MELD score performed similarly to the EuroSCORE II, especially for discriminating morbidities.

Systemic Venous Hypertension and Low Output Are Prevalent at Catheterization in Adults with Pulmonary Atresia and Intact Ventricular Septum Regardless of Repair Strategy

Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early in life, and most survive to a definitive procedure of either Fontan circulation or right ventricle to pulmonary artery (RV-PA) repair. It remains unknown how surgical strategy impacts hemodynamics and comorbidities in adults. Retrospective analysis of adults (age ≥18 years) with PA-IVS undergoing hemodynamic catheterization at Mayo Clinic, MN between January 2000 through January 2020 was performed. 14 patients in the RV-PA group (71% biventricular, 29% 1.5 ventricle repair) and 19 post-Fontan patients [9 lateral tunnel (48%), 6 atriopulmonary (32%), and 4 extracardiac (21%)] were identified. Median age was 29 (21, 34) years. There were no differences in demographics and laboratory data (including MELD-XI) between groups. All patients assessed for liver disease had evidence of hepatic congestion or cirrhosis (14 in the Fontan group and 4 in the RV-PA group). Invasive hemodynamics were comparable between groups with the Fontan and RV-PA groups having similar systemic venous pressure (15.7±4.4 vs. 14.3±6.2, p = .44) and cardiac output (2.2±0.6 vs. 2.0±0.4 L/min/m², p = .23). There was no difference in transplant-free survival (p = .92; 5-year transplant-free survival RV-PA 84%, Fontan 80%). Hemodynamic derangements, namely elevated systemic venous pressure and low cardiac output, are prevalent in patients with PA-IVS undergoing cardiac catheterization regardless of surgical strategy.

Causal relation of tricuspid regurgitation for heart failure outcomes: a mediation analysis of echocardiographic predictors

Aims

Although significant tricuspid regurgitation (TR) is critically associated with heart failure (HF) prognosis, the predictors for large TR impact on HF outcomes remain unknown. This study aimed to identify echocardiographic predictors for a causal relation of TR to HF outcomes.

Methods and results

In a retrospective, acute HF cohort of 462 patients, multivariate logistic regression analysis was performed to determine subgroups with strong association of greater-than-moderate TR with HF readmission or cardiovascular death in a year. We then conducted causal mediation analysis according to persistent atrial fibrillation (Af) or mitral regurgitation (MR) to identify the echocardiographic predictors. The association of TR with HF outcomes was prominent in subgroups of females, with Af, the enlarged indexed tricuspid annular diameter (TADi) or right atrial area, or within certain ranges of the left ventricular ejection fraction, indexed right ventricular end-systolic area, or fractional area change (FAC). Causal mediation analysis found that the TR impact was significant in patients with Af. Furthermore, combination of TADi ≥2.1 cm/m² and FAC ≥30%, which accounted for half of TR patients, predicted a much larger TR impact irrespective of Af and MR. Its prediction ability was superior to that of the modified Model for End-stage Liver Disease score.

Conclusion

The causal impact and burden of TR on HF outcomes was significant in patients with Af, and combining TADi ≥2.1 cm/m² with FAC ≥30% could provide superior echocardiographic prediction of larger TR impact in HF patients.

MELD Score Predicts Outcomes in Patients Undergoing Venovenous Extracorporeal Membrane Oxygenation

Venovenous extracorporeal membrane oxygenation (VV ECMO) is increasingly being used in the management of severe acute respiratory distress syndrome (ARDS). The Respiratory ECMO Survival Prediction (RESP) score is most commonly used to predict survival of patients undergoing ECMO. However, the RESP score does not incorporate renal and hepatic dysfunction which are frequently a part of the constellation of multiorgan dysfunction associated with ARDS. The Model for End-Stage Liver Disease (MELD) incorporates both liver and kidney dysfunction and is used in the risk stratification of liver transplant recipients as well as those undergoing cardiac surgery. The aim of this study was to assess the prognostic value of the MELD score in patients undergoing VV ECMO. Patients undergoing VV ECMO from 2016 to 2019 were extracted from our prospectively maintained institutional ECMO database and stratified based on MELD score. Baseline clinical, laboratory, and follow-up data, as well as post-ECMO outcomes, were compared. Of 71 patients, 50 patients (70.4%) had a MELD score <12 and 21 (29.6%) had a MELD score ≥12. The higher MELD score was associated with increased post-ECMO mortality but reduced risk of dialysis and tracheostomy. In multivariate analysis, higher MELD score (HR 1.35, 95% CI = 1.07-2.75), lower body surface area (HR 0.16, 0.04-0.65), RESP score (HR 0.75, 95% CI = 0.64-0.87), and platelet count (HR 0.99, 95% CI = 0.98-0.99), were significant predictors of postoperative mortality. We conclude that MELD score can be used complementarily to the RESP score to predict outcomes in patients with ARDS undergoing VV ECMO.

Prognostic impact of hepatorenal function in patients undergoing transcatheter tricuspid valve repair

Hepatorenal dysfunction is a strong risk factor in patients with heart failure (HF). We investigated the prognostic significance of hepatorenal dysfunction in 172 consecutive patients undergoing transcatheter tricuspid valve repair (TTVR). The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score was calculated as 5.11 × ln(serum total bilirubin [mg/dl]) + 11.76 × ln(serum creatinine [mg/dl]) + 9.44. Patients were stratified into two groups: high (≥ 14) or low (< 14) MELD-XI score, according to the best cut-off value to predict a one-year composite outcome consisting of all-cause mortality and HF hospitalization. Compared to patients with low MELD-XI score (n = 121), patients with high MELD-XI score (n = 51) had a higher incidence of the composite outcome (47.1% vs. 17.4%; p < 0.0001). In the multivariable analysis, the MELD-XI score was an independent predictor of the composite outcome (adjusted hazard ratio: 1.12; 95% confidence interval [CI] 1.05–1.19; p = 0.0003). In addition, post-procedural TR < 3 + after TTVR was independently associated with a reduction in MELD-XI score six months after TTVR (adjusted odds ratio: 3.37; 95% CI 1.09–10.40; p = 0.03). Thus, the MELD-XI score was associated with the risk of one-year composite outcome, consisting of mortality and HF hospitalization, after TTVR and may help the risk stratification in patients undergoing TTVR.

Prognostic value of hepatorenal function following transcatheter edge-to-edge mitral valve repair

BACKGROUND

Hepatorenal dysfunction is a strong prognostic predictor in patients with heart failure. However, the prognostic impact of the hepatorenal dysfunction in patients undergoing transcatheter mitral valve repair (TMVR) has not been well studied.

METHODS

In consecutive patients who underwent edge-to-edge TMVR at three German centers, the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score was calculated as 5.11 × ln [serum total bilirubin (mg/dl)] + 11.76 × ln [serum creatinine (mg/dl)] + 9.44. Patients were stratified into high (> 11) or low (≤ 11) MELD-XI score of which an incidence of the composite outcome, consisting of all-cause mortality and heart failure hospitalization, within 2 years after TMVR was assessed.

RESULTS

Of the 881 patients, the mean MELD-XI score was 11.0 ± 5.9, and 415 patients (47.1%) had high MELD-XI score. The MELD-XI score was correlated with male, effective regurgitant orifice area, and tricuspid regurgitation severity and inversely related to left ventricular ejection fraction. Patients with high MELD-XI score had a higher incidence of the composite outcome than those with low MELD-XI score (47.7% vs. 29.8%; p < 0.0001), and in multivariable analysis, the high MELD-XI score was an independent predictor of the composite outcome [adjusted hazard ratio (HR) 1.34; 95% confidence interval (CI) 1.02-1.77; p = 0.04). Additionally, the MELD-XI score as a continuous variable was also an independent predictor (adjusted HR 1.02; 95% CI 1.00-1.05; p = 0.048).

CONCLUSIONS

The MELD-XI score was associated with clinical outcomes within 2 years after TMVR and can be a useful risk-stratification tool in patients undergoing TMVR.

Hepatorenal dysfunction predicts operative mortality after triple valve surgery: Utility of MELD-Na

BACKGROUND

Despite significant advancements in operative techniques and myocardial protection, triple valve surgery (TVS) remains a formidable operation with a relatively high in-hospital mortality. We evaluated the prognostic value of Model for End-stage Liver Disease score including sodium (MELD-Na) for mortality after TVS and its predictive value when incorporated in the EuroSCORE risk model.

METHODS

We performed a retrospective cohort study of 61 consecutive patients who underwent TVS from November 2005 to June 2016. Demographics, clinical, biochemical, and operative data were collected and analyzed.

RESULTS

Median follow-up duration was 8.0 years. The majority (70.5%) of patients suffered from rheumatic heart disease and underwent mechanical double valve replacement with tricuspid valve repair. There were six operative deaths (9.84%), with the most common cause of death being multiorgan failure (83.3%). In 26.2% of the cohort, the MELD-Na score was moderately elevated at 9 to 15. A small fraction (4.9%) had a severely elevated MELD-Na greater than 15. Patients with a MELD-Na greater than 9 had a higher unadjusted rate of operative mortality, prolonged ventilation, need for dialysis and acute liver failure after TVS. Hierarchical logistic regression was performed using logistic EuroSCORE as the base model. After risk adjustment, each point of MELD-Na score increase was associated with 1.405 times increase in odds of operative mortality. The regression analysis was repeated by incorporating individual components of the MELD-Na score, including bilirubin, sodium, and albumin. All three biochemical parameters were significantly associated with operative mortality CONCLUSION: MELD-Na score as a quantifier of hepatorenal dysfunction is sensitive and specific for operative mortality after triple valve surgery.

Outcomes of redo-isolated tricuspid valve surgery after left-sided valve surgery

OBJECTIVES

To compare early and long-term outcomes of redo-isolated tricuspid surgery (RITS) after left-sided valve surgery.

METHODS

We retrospectively reviewed 173 patients who underwent RITS for severe tricuspid regurgitation after previous left-sided valve surgery from January 1999 to December 2019. Patients were divided into two groups: RITS by median sternotomy (m-RITS; n = 78) and totally endoscopic approach (e-RITS; n = 95). Perioperative outcomes and follow-up results were analyzed.

RESULTS

There were 19 (11%) in-hospital deaths (14.1% in m-RITS and 8.4% in e-RITS, p = .234) that decreased from 16.7% (1999-2014) to 6.9% (2015-2019) (p = .044). Tricuspid valve replacement (odds ratio [OR] = 4.989, 95% confidence interval [CI]: 1.133-29.790, p = .041) and NYHA function class IV (OR = 9.611, 95% CI: 2.102-43.954, p = .004) were independent risk factors for in-hospital mortality. The overall 1-, 5-, 10-, and 15-year survival rates were 97.2% (95% CI: 94.5%-99.9%), 80.3% (95% CI: 71.7%-88.9%), 59.2% (95% CI: 43.5%-75.5%), and 49.3% (95% CI: 27.2%-71.4%), respectively.

CONCLUSION

Patients undergoing RITS carry a high risk of early mortality. There was no significant difference in early mortality or long-term survival between the endoscopy and median sternotomy, whereas the endoscopy approach was associated with shorter intensive care unit stays and fewer reoperations. Repair resulted in lower surgical mortality than replacement with acceptable residual tricuspid regurgitation.

Contemporary review in the multi-modality imaging evaluation and management of tricuspid regurgitation

The tricuspid valve has gained interest recently because of the poor outcomes with current treatments and advances in percutaneous valve interventions. A sound understanding of the anatomy and pathologies of the tricuspid valve is critical in its evaluation and management of tricuspid regurgitation (TR). A multi-modality imaging approach with transthoracic echocardiography, transesophageal echocardiography, computed tomography, magnetic resonance imaging all have their individual and collective roles in the evaluation of TR and guidance of surgical and percutaneous procedures. This combined with clinical factors will contribute to defining timing, indications, modality selection and risk stratification for tricuspid valve interventions, which currently remains controversial.

Mid-term results after isolated tricuspid valve surgery in the presence of right ventricular leads

BACKGROUND

Patients with tricuspid valve (TV) disease and indication for TV surgery frequently have permanent pacemaker (PM) or defibrillator (AICD) leads, placed in the right ventricle (RV). The aim of this study was to analyse postoperative results and mid-term outcomes after isolated TV surgery (with no further concomitant cardiac procedures) in the presence of permanent RV leads.

METHODS

From January 2005 to January 2019 a total of 80 patients (mean age: 67.7±10.3 yrs; 56.3% male) with isolated TV disease and presence of at least one permanent RV lead in place were referred to our institution for isolated TV repair / replacement; patients with concomitant procedures were excluded for this analysis. All data were retrospectively analysed. The follow-up was 98% complete.

RESULTS

Mean follow-up time was 4.3±3.9 years. Mean preoperative clinical NYHA status was 3.0±0.8, left ventricular ejection fraction 50.7±12.9%, mean pulmonary artery pressure 23.8±9.3mmHg, creatinine 125.7±57.5μmol/l, mean MELD-XI Score (Model of Endstage-Liver Disease excluding INR) was 14.6±5.0 μmol/l. Thirty-day mortality was 6.3% with a 5-years survival of 58.2±6.0%. Cox regression analysis revealed the MELD-XIScore as the only highly significant predictor for postoperative mortality (p=0.002).

CONCLUSIONS

In conclusion, Hepatorenal dysfunction-possibly indicating long lasting TV failure- could be a factor for limited postoperative survival in our patient cohort. This finding could unterline our hypothesis, that early TV surgery may achieve better postoperative survival, even in patients with TV disease caused by RV leads. Further investigations are needed.

Prognostic value and reversibility of liver stiffness in patients undergoing tricuspid annuloplasty

BACKGROUND

Liver stiffness (LS) assessed by transient elastography is associated with adverse events in patients with heart failure. However, the predictive value of LS for adverse outcome is uncertain in patients undergoing tricuspid annuloplasty (TA). This study sought to evaluate the prognostic value and reversibility of LS in patients undergoing TA during left-sided valve surgery.

METHODS AND RESULTS

A total of 158 patients who underwent TA were prospectively evaluated. Patients were divided into three groups according to tertile of LS. Adverse outcome was defined as heart failure that required hospital admission or all-cause mortality following TA. The median LS was 13.9 (inter-quartile range 8.1-22.3) kPa and independently correlated positively with tricuspid regurgitation (TR) severity, inferior vena cava diameter and negatively with tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis revealed that LS was an independent predictor of adverse events. Significant improvement in LS at 1-year post-TA (13.1-7.8 kPa, P < 0.01) was noted only in patients who had no adverse events, not in those who experienced heart failure (17.1-14.2 kPa, P = 0.87) and seems to be linked to an absence of TR recurrence.

CONCLUSIONS

This study demonstrated that LS is predictive of adverse outcome and is reversible in patients undergoing TA without TR recurrence at 1 year. These findings suggest that assessing LS, an integrative correlate of right heart condition, may aid the pre-operative risk assessment of candidate for heart surgery including TA.

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

OBJECTIVES

Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery.

METHODS

From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival.

RESULTS

At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome.

CONCLUSIONS

Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

Prognostic Role of Hepatorenal Function Indexes in Patients With Ebstein Anomaly

BACKGROUND

Hepatorenal dysfunction is a risk factor for mortality in patients with chronic tricuspid regurgitation due to acquired heart disease. Ebstein anomaly is the most common cause of primary tricuspid regurgitation in adults with congenital heart disease, but the prevalence and prognostic implications of hepatorenal dysfunction are unknown in this population.

OBJECTIVES

The purpose of this study was to determine the risk factors and prognostic implications of hepatorenal dysfunction, as measured primarily by the use of model for end-stage liver disease excluding international normalized ratio (MELD-XI score), as well as looking at other associated factors.

METHODS

This was a retrospective study of adults with Ebstein anomaly who received care at Mayo Clinic from 2003 to 2018.

RESULTS

Of 692 patients, the median MELD-XI score was 10.2 (interquartile range: 9.4 to 13.3); 53 (8%) died and 3 (0.4%) underwent heart transplant. MELD-XI was an independent predictor of death/transplant (hazard ratio: 1.32; 95% confidence interval: 1.11 to 2.06; p < 0.001). In the subset of patients with serial MELD-XI scores (n = 416), temporal change in MELD-XI score (ΔMELD-XI) was also a predictor of death/transplant. In the subset of patients who underwent tricuspid valve surgery (n = 344), a post-operative improvement in MELD-XI score (ΔMELD-XI) was associated with improved long-term survival. Impaired right atrial (RA) reservoir strain and elevated estimated RA pressure were associated with worse baseline MELD-XI and ΔMELD-XI scores.

CONCLUSIONS

Hepatorenal dysfunction is a predictor of mortality in Ebstein anomaly, and RA dysfunction and hypertension are hemodynamic biomarkers that can identify patients at risk for deterioration in hepatorenal function and mortality. These data highlight the prognostic importance of noncardiac organ-system dysfunction, and provide complementary clinical risk stratification metrics for management of these patients.

Pretransplantation and Post-Transplantation Liver Disease Assessment in Adolescents Undergoing Isolated Heart Transplantation for Fontan Failure

OBJECTIVE

To describe the assessment of Fontan-associated liver disease and determine the clinical and imaging measures that may identify hepatic morbidity risk in isolated heart transplantation candidates and trend those measures post-isolated heart transplantation.

STUDY DESIGN

Retrospective analysis of pre-isolated heart transplantation and post-isolated heart transplantation Fontan-associated liver disease (FALD) status using blood tests, magnetic resonance imaging (MRI), and liver biopsy analysis within 6 months before isolated heart transplantation and 12 months after isolated heart transplantation in 9 consecutive patients with Fontan. Pre- and post-isolated heart transplantation standard laboratory values; varices, ascites, splenomegaly, thrombocytopenia (VAST) score; Fontan liver MRI score; liver biopsy scores; Model for End-stage Liver Disease (MELD); MELD excluding the International Normalized Ratio (MELD-XI); AST to platelet ratio index, and cardiac catheterization data were compared.

RESULTS

Pretransplantation maximum MELD and MELD-XI was 15 and 16, respectively. Central venous pressures and VAST scores decreased significantly post-transplantation. In 5 paired studies, Fontan liver MRI score maximum was 10 pretransplantation and decreased significantly post-transplantation. Arterially enhancing nodules on MRI persisted in 2 patients post-transplantation. Pretransplantation and post-transplantation liver biopsy scores did not differ in 4 paired biopsy specimens.

CONCLUSIONS

Patients with FALD and MELD <15, MELD-XI <16, Fontan liver MRI score <10, and VAST score ≤2 can have successful short-term isolated heart transplantation outcomes. Liver MRI and VAST scores improved post-transplantation. Post-transplantation liver biopsy scores did not change significantly. Pretransplantation liver biopsy demonstrating fibrosis alone should not exclude consideration of isolated heart transplantation. The persistence of hepatic vascular remodeling and fibrosis post-isolated heart transplantation suggests that continued surveillance for hepatic complications post-transplantation for patients with Fontan is reasonable.

The prognostic value of MELD-XI in elderly patients with ST-segment elevation myocardial infarction: an observational study

Background

The model for end-stage liver disease excluding international normalized ratio (MELD-XI) is a simple score for risk assessment. However, the prognostic role of MELD-XI and its additional value to current risk assessment in elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is uncertain.

Methods

In all, 1029 elderly patients with STEMI undergoing PCI were consecutively included and classified into three groups according to the TIMI risk score: low-risk (≤ 3, n = 251); moderate-risk (4–6, n = 509); and high-risk (≥ 7, n = 269) groups. Multivariate analysis was performed to identify risk factors for adverse events.

Results

The overall in-hospital mortality was 5.3% and was significantly higher in the high-risk group (1.2% vs. 3.3% vs. 13.0%, p < 0.001). The optimal cut-off of the TIMI risk score and MELD-XI for in-hospital death was 7 and 13, respectively. MELD-XI was associated with in-hospital (adjusted odds ratio = 1.09, 95% CI = 1.04–1.14, p = 0.001) and one-year (adjusted hazard ratio = 1.05, 95% CI = 1.01–1.08, p = 0.005) mortality independently of the TIMI risk score. Combining TIMI risk score and MELD-XI exhibited better predictive power for in-hospital death than TIMI risk score (area under the curve [AUC] = 0.810 vs. 0.753, p = 0.008) or MELD-XI alone (AUC = 0.810 vs. 0.750, p = 0.018). Patients with TIMI risk score ≥ 7 and MELD-XI ≥ 13 had the worst prognosis.

Conclusion

MELD-XI could be considered as a risk-stratified tool for elderly patients with STEMI undergoing PCI. It had an additive prognostic value to TIMI risk score.

Modified model for end-stage liver disease score predicts 30-day mortality in high-risk patients with acute pulmonary embolism admitted to intensive care units

OBJECTIVES

The Model for End-stage Liver Disease excluding the international normalised ratio that is derived from prothrombin time which is calculated as a ratio of the patient's prothrombin time to a control prothrombin time standardized (MELD-XI) and modified MELD, which uses albumin in place of the international normalised ratio (MELD-Albumin) scores reflect liver and renal function and are predictors of mortality. However, their prognostic value in acute pulmonary embolism (APE) has not been studied.

DESIGN

We assessed the predictive value of the MELD scores in patients diagnosed with high-risk APE admitted to the intensive care unit. The primary outcome was 30-day mortality.

RESULTS

Of the 273 patients included in the study, 231 were survivors and 42 were non-survivors. The mortality rate was 15.3%. The mean MELD-XI and MELD-Albumin scores were significantly higher in the non-survivors than in the survivors (MELD XI, 11.8 ± 1.8 and 10.6 ± 1.43, respectively; p = .002; MELD-Albumin, 10.5 ± 1.6 and 8.7 ± 1.1, respectively; p = .001). The multiple logistic regression analysis identified the MELD-XI (hazard ratio: 3.029, confidence interval: 1.06-1.21, p = .007) and MELD-Albumin (hazard ratio: 1.13, confidence interval: 1.06-1.21, p = .002) scores as independent predictors of mortality. Receiver operating characteristic analysis revealed that the predictive power of the MELD-Albumin score (0.871 ± 0.014; p < .001) was higher than those of the MELD-XI (0.726 ± 0.022, p < .001), APACHE III (0.682 ± 0.024, p < .001), and PESI (0.624 ± 0.023, p < .001) scores.

CONCLUSIONS

The MELD-Albumin score is an easily calculable, reliable, and practical risk assessment tool and independent predictor of 30-day mortality in patients with high-risk APE.

MicroRNA-29b/c-3p Indicate Advanced Liver Fibrosis/Cirrhosis in Univentricular Heart Patients With and Without Fontan Palliation

Aim: The present study aims to identify those microRNAs (miRNAs) in patients with univentricular heart (UVH) disease with and without Fontan palliation that may be associated with advanced liver fibrosis/cirrhosis. Materials and Methods: SurePrint™ 8 × 60K Human v21 miRNA arrays were used to determine the miRNA abundance profiles in the blood of 48 UVH patients with and without Fontan palliation and 32 matched healthy controls. The abundance levels of selected miRNAs have been validated by quantitative reverse transcription-polymerase chain reaction (RT-qPCR). Results: According to microarray analysis, 50 miRNAs were found to be significantly abundant in UVH patients of which miR-29b-3p and miR-29c-3p were significantly related to the model of end-stage liver disease (MELD)-Albumin and albumin-bilirubin (ALBI) score representing advanced liver fibrosis/cirrhosis. Relative expression levels of both miRNAs were significantly higher in patients with a higher collapsibility index representing venous hepatic congestion, a higher MELD-Albumin or ALBI score and incomplete or no Fontan palliation. In the logistic regression analysis, a MELD-Albumin score ≥ 11 or ALBI score > -2.6 were best predicted by total bilirubin (OR 6.630, P = 0.016), albumin (OR 0.424, P = 0.026), and miR-29c-3p (OR 33.060, P = 0.047). After adjustment to the status of Fontan palliation, however, no statistical significance of these parameters was found thus underlining the importance of palliation status on progression of liver fibrosis/ cirrhosis in UVH patients. Conclusions: In UVH patients with and without Fontan palliation, miR-29b-3p and miR-29c-3p seem to be markers of advanced liver fibrosis/cirrhosis and thus may be used in the risk assessment of these patients.

MELD-XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end-stage liver disease-excluding international normalized ratio (MELD-XI) scoring system has been shown to have prognostic value in other critically ill patient populations.

MATERIALS AND METHODS

A single-center retrospective review was performed for all adult patients managed on VA-ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD-XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD-XI in regard to in-hospital mortality.

RESULTS

Of the 187 patients, 74 (40%) patients had MELD-XI less than 14 (low-risk) and 113 (60%) had a MELD-XI of 14 or greater (high-risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high-risk MELD-XI group had significantly greater mortality during index hospitalization compared to the low-risk group (74% vs 39%; P < .0001). Quartile stratification demonstrated progressively worse prognosis associated with higher MELD-XI scores; the fourth quartile showed a ninefold increased risk of mortality compared to the first quartile (P < .001). The AUC for predicting index hospitalization mortality was 0.69 (95% CI, 0.62-0.77) with a Youden index (J) of 0.36 and optimized cutoff of 12.98.

CONCLUSIONS

These findings suggest that the MELD-XI scoring system can be applied to the VA-ECMO patient population early in their course of ECMO as a prognostic tool to aid in complex clinical decision making.