217 Risk-Stratification of Heart Transplant (HTX) Candidates with Advanced Liver Dysfunction

Abstract

Purpose: HTX candidates frequently have liver dysfunction. Identification of patients who may proceed to heart transplant or need dual organ transplant is difficult. Models of End-Stage Liver Disease (MELD) score has been shown to predict outcomes in HTX patients. Whether MELD score, liver biopsy, hemodynamics or echocardiography differentiates these patients was investigated. Methods and Materials: Retrospective chart review of all patients evaluated for HTX at Columbia University from 1/00-10/10 identified 37 patients with liver disease who underwent liver biopsy. Echo, right heart cath and MELD were available in all patients; 22 patients had liver hemodynamics. Results: 25 patients were listed for HTX, and 12 patients were rejected secondary to advanced liver disease. Etiology of liver disease was: HCV (11), alcohol (5), amiodarone toxicity (5), congestive hepatopathy (15) and infiltrative disease (1). 15 patients were transplanted: 14 male, age 56 6 years. 75% had mod-severe RV dysfunction, mean RA 14.4 6.6 mmHg, mean hepatic wedge 21.7 7 and MELD 14 4.4. Liver pathology showed 2 with cirrhosis, 2 with moderate and 11 with minimal fibrosis. One and 5 year survival was 94%, and 85%. Of the remaining 10 listed patients, 9 died prior to HTX. Hemodynamics, pathology and MELD were similar to those transplanted (MELD 13.3 5.5). Of the rejected patients, 80% were male, age 52 14 years. 75% had mod-severe RV dysfunction, mean RA 19 7, mean hepatic wedge 22.7 4.5 and MELD 17 7.3. Liver pathology showed 5 with cirrhosis, 4 moderate and 3 with minimal fibrosis. 9 of 12 patients died. MELD score for all 37 patients did not correlate with liver fibrosis severity. Conclusions: Rejected candidates had modestly worse hemodynamics and MELD when compared to accepted candidates, with more advanced liver pathology. Liver pathology identifies patients who might benefit from dual organ transplant, whereas MELD might identify their surgical risk. High mortality on the transplant waitlist reflects organ shortage and inability to offer device therapy to these patients.