Model For End-Stage Liver Disease Excluding INR Score Research Articles

MELD score is predictive of 90-day mortality after veno-arterial extracorporeal membrane oxygenation support.

The Model for End-Stage Liver Disease (MELD) score was originally described as a marker of survival in chronic liver disease. More recently, MELD and its derivatives, MELD excluding INR (MELD-XI) and MELD with sodium (MELD-Na), have been applied more broadly as outcome predictors in heart transplant, left ventricular assist device placement, heart failure, and cardiogenic shock, with additional promising data to support the use of these scores for prediction of survival in those undergoing veno-arterial extracorporeal membrane oxygenation (VA ECMO). This study assessed the prognostic impact of MELD in patients with cardiogenic shock undergoing VA ECMO via a single-center retrospective review from January 2014 to March 2020. MELD, MELD-XI, and MELD-Na scores were calculated using laboratory values collected within 48 h of VA ECMO initiation. Multivariate Cox regression analyses determined the association between MELD scores and the primary outcome of 90-day mortality. Receiver operating characteristics (ROC) were used to estimate the discriminatory power for MELD in comparison with previously validated SAVE score. Of the 194 patients, median MELD was 20.1 (13.7-26.2), and 90-day mortality was 62.1%. There was a significant association between MELD score and mortality up to 90 days (hazard ratio (HR) = 1.945, 95% confidence interval (95% CI) = 1.244-3.041, p = 0.004) after adjustment for age, indication for VA ECMO, and sex. The prognostic significance of MELD score for 90-day mortality revealed an AUC of 0.645 (95% CI = 0.565-0.725, p < 0.001). MELD-Na score and MELD-XI score were not associated with mortality. MELD score accurately predicts long-term mortality and may be utilized as a valuable decision-making tool in patients undergoing VA ECMO.

The predictive value of the MELD-XI score for short- and long-term mortality in elderly patients with non-ST elevation myocardial infarction.

In this study, we investigated the utility of the Model for End-stage Liver Disease excluding INR (MELD-XI) score in predicting short- and long-term mortality in elderly patients with non-ST elevation myocardial infarction (NSTEMI) who underwent coronary angiography (CAG). In total, we analyzed 228 elderly NSTEMI patients above the age of 75. We used the modified 5-item frailty index and the Charlson Comorbidity Index (CCI) to assess the comorbidities. The MELD-XI score was calculated using the logarithmic relationship between the serum creatinine and total bilirubin. The median long-term follow-up was 530 [interquartile range (IQR) = 303-817] days and the short- and long-term mortality rates were 11.8% (n = 27) and 16.4% (n = 33), respectively. Patients who did not survive had a substantially higher MELD-XI score than those who did [10.1 (IQR = 7.8-15.1) vs. 4.5 (IQR = 1.9-6.9), p < 0.001, respectively]. Multivariable Cox regression analyses indicated that the MELD-XI score predicted both short- and long-term mortality independently. When the MELD-XI score, serum creatinine, and total bilirubin area under the curve (AUC) values were compared to predict long-term mortality, the MELD-XI score had the highest value (AUC: 0.833), followed by the serum creatinine (AUC: 0.741), and the total bilirubin (AUC: 0.723). The accuracy of the MELD-XI score was further tested with the GRACE risk score, which demonstrated noninferiority. This was the first investigation which indicated that elderly NSTEMI patients with a high MELD-XI score had poor prognosis in the short- and long-term period.

Elevated markers of liver function are associated with poorer outcomes in HFREF: an analysis of DAPA-HF

Abstract Background Abnormalities of liver tests in patients with heart failure with reduced ejection fraction (HFrEF) is a well-recognised phenomenon. We examined the prognostic value of measures of liver function in a large contemporary cohort of patients with HFrEF enrolled in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial Methods In this post-hoc analysis of the DAPA-HF trial we studied 4625 patients with liver function tests available at baseline. Cox proportional hazards models were used to assess the association between liver tests (total bilirubin, alkaline phosphatase [ALP], alanine transaminase [ALT], aspartate transaminase [AST]) and the Model for End-stage Liver Disease excluding INR (MELD-XI) score (calculated as 5.11 Ln [total bilirubin as mg/dL] + 11.76 Ln [creatinine as mg/dL] + 9.44), and the risk of the primary composite endpoint (hospitalisation or urgent visit for heart failure or cardiovascular death). Models were adjusted for age, sex, race, region, systolic blood pressure, heart rate, LVEF, eGFR, log-transformed NT-proBNP, NYHA class, history of hypertension, stroke, myocardial infarction, atrial fibrillation, heart failure aetiology and randomized treatment to dapagliflozin and stratified by diabetic status at baseline. An interaction term between each measure and the effect of treatment on the primary composite outcome was tested as a fractional polynomial. Results Total bilirubin, ALP, and MELD-XI score were associated with a higher risk of all the primary outcome (Figure 1) but not ALT or AST. These relationships persisted after adjustment: total bilirubin per log unit increase (HR=1.46; 95% CI 1.28 – 1.67, p&amp;lt;0.001), ALP per log unit increase (HR=1.39; 95% CI 1.15 – 1.66, p&amp;lt;0.001), MELD-XI per 1 SD increase (HR 1.27; 95% CI 1.13 – 1.42, p&amp;lt;0.001). The effect of dapagliflozin on the primary outcome was not modified by the baseline levels of either total bilirubin, ALP or MELD-XI score (Figure 2) Conclusions Higher total bilirubin, ALP and MELD-XI score were independently associated with a higher risk of cardiovascular death or worsening HF and may be useful routinely available biomarkers to assess prognosis. The efficacy of dapagliflozin was the not modified by baseline levels of any of these markers. Funding Acknowledgement Type of funding sources: None. Figure 2

Significance of pre and post-implant MELD-XI score on survival in children undergoing VAD implantation

Derangements in liver and renal function often accompany end-stage heart failure. We sought to assess the utility of an objective risk assessment tool, the Model for End-stage Liver Disease eXcluding INR (MELD-XI), to identify pediatric patients at increased risk for adverse outcomes post-ventricular assist device (VAD) implantation. The Pedimacs database was queried for all pediatric patients who underwent VAD implantation from September 19, 2012 to December 31, 2019. Pre-implant and early (1-week) post-implant MELD-XI scores were used to stratify patients into low, intermediate and high score cohorts. Comparison of pre-implant characteristics and post-implant outcomes were conducted across groups. Multiphase parametric hazard modeling was utilized to identify independent predictors of post-implant mortality. A total of 742 patients had a calculable MELD-XI score pre-implant. When stratified by MELD-XI scores pre-implant, patients in the high MELD-XI score cohort (score >13.6) had inferior survival and increased bleeding, renal dysfunction and respiratory failure post-implant compared to intermediate and low score cohorts. Risk factors for mortality post-VAD implantation were: increasing MELD-XI scores (HR 1.1 per 1 unit rise), Pedimacs profile 1 (HR 1.6), congenital heart disease (HR 2.3) and being on a percutaneous VAD (HR 2.7). Importantly, MELD-XI score was a better predictor of post-VAD implant mortality than bilirubin or creatinine alone, neither of which were significant in the final model. Patients with increasing or continued high MELD-XI scores early post-implant had the worst survival. The MELD-XI is an easily calculated score that serves as a promising risk assessment tool in identifying children at risk for poor outcomes post VAD implantation.

MELD-XI score is not associated with adverse outcomes in ambulatory adults with a Fontan circulation

BackgroundThe Model for End-stage Liver Disease excluding INR (MELD-XI) is commonly used to identify patients with a Fontan circulation at increased risk of adverse events, However, this approach has not been evaluated in unselected ambulatory adults. MethodsWe enrolled a cohort of 163 outpatients with a Fontan circulation aged ≥18-years in the Boston Adult Congenital Heart Disease Biobank from 2012 to 2018. Survival analysis was performed to assess the relationship between MELD-XI with both all-cause mortality and a composite outcome of mortality or non-elective cardiovascular hospitalization. ResultsMean age was 30.2±9.7 years, and 41.1% were women. Most had a lateral tunnel Fontan (62.6%). MELD-XI score averaged 10.6±2.1 (median = 13). Both creatinine and total bilirubin were ≤1.0 mg/dL in 94/163 (57.7%), translating to the lowest possible score. MELD-XI<11 was present in 123 patients (75.5%), while only 3 (1.8%) had MELD-XI>18. During follow-up of 3.2±2.2 years, the composite outcome occurred in 58 patients (35.6%), with 16 deaths (9.8%). Most deaths (n = 11, 68.8%) and composite outcomes (n = 39, 67.2%) occurred among patients with MELD-XI less than the median. MELD-XI score did not differ between those who did and did not have events (death: 10.8±2.2 vs. 10.6±2.1; p = 0.92; composite outcome: 10.6±2.2 vs. 10.7±2.1, p = 0.45). Likewise, survival analysis did not suggest an association between MELD-XI and either outcome. ConclusionsMELD-XI score does not appear to be associated with risk for adverse outcomes in an unselected cohort of outpatients with a Fontan circulation. Prior findings may reflect conditioning on a clinical referral for laboratory testing.

Hepatorenal dysfunction assessment with the Model for End-Stage Liver Disease Excluding INR score predicts worse survival after heart transplant in pediatric Fontan patients

BackgroundFontan physiology results in multiorgan dysfunction, most notably affecting the liver and kidney. We evaluated the utility of Model for End-Stage Liver Disease Excluding INR (MELD-XI) score, a score evaluating the function of both liver and kidney to identify Fontan patients at increased risk for morbidity and mortality post–heart transplant. MethodsThe Pediatric Heart Transplant Society database was queried to identify Fontan patients listed for heart transplant between January 2005 and December 2018. MELD-XI scores were calculated at listing and heart transplant. A multivariable analysis was conducted to identify risk factors for post–heart transplant mortality. Demographic, clinical characteristics, and survival differences were evaluated and compared between the high and low MELD-XI score cohorts. The impact of changing MELD-XI scores during the waitlist period on post–heart transplant outcomes was also evaluated. ResultsOf 565 Fontan patients who underwent transplantation, 524 (93%) had calculable MELD-XI scores at the time of heart transplant: 421 calculable at listing and 392 calculable at listing and at heart transplant. On multivariable analysis, only MELD-XI score (squared) (hazard ratio, 1.007), history of protein-losing enteropathy (hazard ratio, 2.1), and ventricular assist device use at transplant (hazard ratio, 3.4) were risk factors for early phase post–heart transplant mortality. Patients with high MELD-XI scores at heart transplant had inferior survival post–heart transplant (P = .02); those in the high MELD-XI score cohort at wait listing and heart transplant tend to have the worst post–heart transplant survival; however, this was not significant (P = .42). ConclusionsThe MELD-XI, an easily calculated score, serves as a valuable aid in identifying pediatric Fontan patients at increased risk for post–heart transplant mortality.

Abstract 12917: Prognostic Value of the Combination of Model for End-stage Liver Disease Excluding Inr Score and Non-alcoholic Fatty Liver Disease Fibrosis Score in Patients Admitted for Acute Heart Failure

Background: Cardiohepatic interactions have been a focus of attention in heart failure(HF), and the model for end-stage liver disease excluding INR (MELD-XI) has been shown to be useful for prediction of poor outcome in patients (pts) with acute decompensated heart failure (ADHF). Furthermore, it has been reported that liver stiffness predicts adverse prognosis in pts with HF. Liver fibrosis is assessed by non-invasive fibrosis markers such as Fibrosis-4 (FIB4) index, non-alcoholic fatty liver disease fibrosis score (NFS) and aminotransferase to platelet ratio index (APRI). Recently, a new group of HF pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is little information available on the comparison of prognostic significance of MELD-XI and liver fibrosis scores in ADHF pts, relating to LVEF. Methods: We prospectively studied 466 consecutive ADHF pts (HFrEF (LVEF≦40%): n=164, HFmrEF (40&lt;LVEF&lt;50): n=104 and HFpEF (LVEF≧50%): n=198). At the discharge, we calculated MELD-XI, FIB4 index , NFS, and APRI. The endpoint was all cause death (ACD). Results: During a follow-up period of 2.8±1.5 years, 143 pts had ACD. At multivariate Cox analysis, MELD-XI and FIB4 index was independently associated with ACD irrespective of LVEF. The pts with both greater MELD-XI ([HFrEF]≥25.8, [HFmrEF]≥33.2, [HFpEF]≥30.1) and greater FIB4 index ([HFrEF]≥2.58, [HFmrEF]≥2.58, [HFpEF]≥2.22) had a significantly increased risk of ACD than those with either and none of them in all three groups. Conclusions: The combination of MELD-XI and FIB4 index might be useful for stratifying pts at risk for ACD in ADHF pts with irrespective of LVEF.

Model for End-Stage Liver Disease Excluding INR (MELD-XI) Score Predicts Outcomes in Pediatric Patients Supported with Ventricular Assist Device: An Analysis of the PediMACS Registry

Our study aims to identify the utility of pre-implant MELD-XI score in identifying pediatric patients at higher risk for morbidity and mortality post-VAD implant. We reviewed all patients listed in the PediMACS database from 9/19/12 to 3/31/19. Patients missing bilirubin or creatinine that precluded calculation of MELD-XI score (n=89) were excluded. Patients were divided into three cohorts based on MELD-XI score pre-implant - low (minimum score 9.4, < 25%-tile), intermediate (scores 9.4-13.6, 25-75%-tile), and high (scores >13.6, 75-100%-tile). Baseline clinical and hemodynamic data were compared; outcomes data on morbidity and mortality were compared across groups. Of 596 patients included, 42.5% were in the low, 29.2% in the intermediate and 28.3% in the high MELD-XI cohort. Compared to the low and intermediate cohorts, patients in the high MELD-XI cohort were significantly older (p<0.01); more likely had congenital heart disease (17.8 vs. 24.7 vs. 30.2%, p<0.01); elevated NT-pro BNP, elevated AST and ALT (p<0.05). They were more likely to be mechanically ventilated, on ECMO and INTERMACS 1 (p<0.01) pre-implant. Compared to the low-MELD-XI cohort, patients in the high MELD-XI cohort had an increased risk of death [14.7 vs. 29.5%, p<0.01] (Figure) and a lower probability of transplant [69.4 vs. 50.1, p<0.01] at 12 months post-VAD implant. On multivariable analysis, a high MELD-XI score persisted as highly significant risk factor for early mortality (HR 1.7, p<0.01) (Table). Pediatric patients with an elevated MELD-XI score have higher acuity of illness pre-implant. This easily calculated score based on routinely collected lab values serves as a promising risk assessment tool in identifying pediatric VAD recipients at increased risk for mortality post VAD implant. Trending the MELD-XI score in patients with advanced heart failure may aid clinicians in timing of VAD implantation.

Trends in MELD-XI between Listing and Transplant are Associated with Poor Outcomes in Heart Transplant Recipients with Stage 3 Chronic Kidney Disease

Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at significantly higher risk of mortality and poor renal outcomes compared with those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT alone. The Model for End-Stage Liver Disease Excluding INR (MELD-XI) score at the time of HT has been shown to predict early post-HT mortality. We investigated whether trends in the MELD-XI score between listing and transplant among those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m2) are associated with higher risk of post-HT death or dialysis. We identified 159 patients undergoing HT at our institution between 1/2009 and 2/2018. The following groups were created: Group 1 - MELD-XI ≤ 16 at listing and HT, Group 2 - MELD-XI ≤ 16 at listing and > 16 at HT, Group 3 - MELD-XI > 16 at listing and ≤ 16 at HT, Group 4 - MELD-XI > 16 at listing and HT. A cutoff of 16 was chosen based on the 75th percentile in a normal distribution among those without a composite outcome of post-HT death or dialysis at 1 year. Cox-proportional regression and survival analyses were performed to assess risk of this outcome. Average MELD-XI at listing was 14.0 ± 4.9 and at HT was 12.8 ± 4.5 (p < 0.01); MELD-XI >16 was present in 51 (32.1%) at listing and 38 (23.9%) at HT. Group 4 incurred highest risk of composite outcome relative to Group 1 (adjusted hazard ratio 3.67 (95% confidence interval: 1.38-9.76, p < 0.01); see figure). Notably, Groups 2 and 3 had a statistically nonsignificant trend toward higher risk of the composite outcome compared to Group 1. Changes in MELD-XI between listing and transplantation offer additional risk stratification beyond absolute MELD-XI at time of transplant for death or dialysis at 1 year in patients with stage 3 CKD.

Prognostic value of the model for end-stage liver disease excluding INR score (MELD-XI) in patients with adult congenital heart disease.

Patients with adult congenital heart disease (ACHD) are at increased risk of developing late cardiovascular complication. However, little is known about the predictive factors for long-term outcome. The Model for End-Stage Liver Disease eXcluding INR (MELD-XI) score was originally developed to assess cirrhotic patients and has the prognostic value for heart failure (HF) patients. In the present study, we examined whether the score also has the prognostic value in this population. We retrospectively examined 637 ACHD patients (mean age 31.0 years) who visited our Tohoku University hospital from 1995 to 2015. MELD-XI score was calculated as follows; 11.76 x ln(serum creatinine) + 5.11 x ln(serum total bilirubin) + 9.44. We compared the long-term outcomes between the high (≥10.4) and the low (<10.4) score groups. The cutoff value of MELD-XI score was determined based on the survival classification and regression tree (CART) analysis. The major adverse cardiac event (MACE) was defined as a composite of cardiac death, HF hospitalization, and lethal ventricular arrhythmias. During a mean follow-up period of 8.6 years (interquartile range 4.4–11.4 years), MACE was noted in 51 patients, including HF hospitalization in 37, cardiac death in 8, and lethal ventricular arrhythmias in 6. In Kaplan-Meier analysis, the high score group had significantly worse MACE-free survival compared with the low score group (log-rank, P<0.001). Multivariable Cox regression analysis showed that the MELD-XI score remained a significant predictor of MACE (hazard ratio 1.36, confidence interval 1.17–1.58, P<0.001) even after adjusting for patient characteristics, such as sex, functional status, estimated glomerular filtration rate, and cardiac function. Furthermore, CART analysis revealed that the MELD-XI score was the most important variable for predicting MACE. These results demonstrate that the MELD-XI score can effectively predict MACE in ACHD patients, indicating that ACHD patients with high MELD-XI score need to be closely followed.

Easy prognostic assessment of concomitant organ failure in critically ill patients undergoing mechanical ventilation

BackgroundAcute respiratory distress syndrome (ARDS) is a life-threatening disease. We evaluated the prognostic utility of Model for End-stage Liver Disease excluding INR (MELD-XI) score for predicting mortality in a cohort of critically ill patients on mechanical ventilation. MethodsIn total, 11,091 mechanically ventilated patients were included in our post-hoc retrospective analysis, a subgroup of the VENTILA study (NCT02731898). Evaluation of associations with mortality was done by logistic and Cox regression analysis, an optimal cut-off was calculated using the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points). ResultsPeak-, plateau- and positive end-expiratory pressure were higher in patients with MELD-XI>12. Patients with MELD-XI>12 had higher driving pressures (14 ± 6 cmH2O versus 13 ± 6; p < 0.001). MELD-XI was associated with 28-day mortality after correction for relevant cofounders including SAPS II and ventilation pressures (HR 1.04 95%CI 1.03–1.05; p < 0.001. Patients with MELD-XI>12 evidenced both increased hospital (46% versus 27%; p < 0.001) and 28-day mortality (39% versus 22%). ConclusionsMELD-XI is independently associated with mortality and constitutes a useful and easily applicable tool for risk stratification in critically ill patients receiving mechanical ventilation.Trial registration: NCT02731898, registered 4 April 2016.

MELD-XI score predicts in-hospital mortality independent of simplified pulmonary embolism severity index among patients with intermediate-to-high risk acute pulmonary thromboembolism.

Acute pulmonary thromboembolism (PTE) is a highly morbid and fatal condition. Although several risk stratification models exist for prediction of mortality risk in PTE, no study has yet focused on the effect of impaired vital organ function, such as renal or hepatic impairment, on mortality in PTE. MELD-XI (Model for end-stage liver disease excluding INR) score predicts mortality among patients with end-stage hepatic and cardiovascular disorders. Herein, we aimed to test MELD-XI score for predicting in-hospital prognosis of patients with intermediate-to-high risk acute PTE. We reviewed the medical records patients older than 18 years hospitalized with intermediate-to-high risk PTE between 01.06.2011 and 01.01.2019. Simplified pulmonary embolism severity index (sPESI) score and MELD-XI score were calculated, and in-hospital mortality determined. MELD-XI score was compared between patients with and without in-hospital mortality and was correlated to sPESI score. The predictive power of MELD-XI score for in-hospital mortality was sought and an in-hospital survival analysis with Kaplan Meier curve and log-rank test was done for MELD-XI score. A total of 104 patients [mean age of 70.8 ± 15.9 years; 68 (65.4%) females]. Fourteen (13.5%) patients died at hospital. MELD-XI and sPESI scores were significantly correlated to each other and were higher in deceased patients than the survivors [17.3 (IQR 14.3) vs. 10.12 (IQR 2.99); p<0.05 and 2 (IQR 1) vs. 1 (IQR 1); p<0.05, respectively]. MELD-XI score and sPESI score were significant predictor of in-hospital mortality in multivariate analysis. A MELD-XI score ≥ 10.25 had a sensitivity of 78.6% and a specificity of 70.0% for in-hospital mortality. A survival analysis revealed that a high MELD-XI category (MELD-XI score ≥ 10.2) significantly worsened in-hospital survival (p<0.01; log rank test). MELD-XI score performs well for mortality prediction among patients with intermediate-to-high risk PTE. This subject needs to be further studied by large, randomized controlled studies.

MELD-XI Score Predicts Post-Heart Transplant Survival in Fontan Patients: A PHTS Analysis

Purpose As heart transplant (HT) outcomes in Fontan patients have improved, there is interest in identifying markers of liver disease associated with increased mortality. In adults, an elevated Model for End Stage Liver Disease eXcluding INR (MELD-XI) score is associated with worse post-HT outcomes. We evaluated the relationship between MELD-XI scores at transplant and post-HT morbidity and mortality in Fontan patients. Methods The Pediatric Heart Transplant Society Registry was queried to identify pediatric Fontan patients listed for HT from 2005-2017. The MELD-XI score was calculated [MELD-XI= 5.112 x ln(total bilirubin) + 11.76 x ln(creatinine) + 9.44] at time of transplant. Those patients with a MELD-XI score at the time of HT above the 75thpercentile of the entire cohort were classified as the high MELD-XI score cohort; All others formed the low MELD-XI score cohort. Results Of 698 Fontan patients listed, 506 (73%) underwent HT. A score ≥ 11.5 identified the high MELD-XI score cohort. At HT, patients in the high MELD-XI cohort were more likely to be older (12 ±5.0 vs. 10.8 ±4.8 y, p=0.05), listed UNOS Status 1A (82% vs. 72%, p=0.05), on a ventilator (11% vs. 3%, p=0.001) and on ECMO (9.1% vs. 2.6%, p=0.009). There was no difference in time to first infection, treated rejection, CAV or malignancy between groups. However, both allograft and patient survival (Figure) was inferior in the high MELD-XI score cohort (p=0.02 and p=0.01 respectively). Multiphase parametric hazard modeling demonstrated that high MELD-XI score (HR=1.2, p Conclusion Pediatric Fontan patients with high MELD-XI scores and those who require mechanical circulatory support have increased mortality post-HT. Identification of Fontan patients with high MELD-XI scores during patient selection or while awaiting HT allows for active management of this risk factor which may reduce post-HT mortality.

OC31 HOW TO IDENTIFY THE APPROPRIATE LEFT VENTRICULAR ASSIST DEVICE CANDIDATE AMONG PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT

Background and Aim: Implantation of long-term left ventricular assist devices (LVADs) in patients on veno-arterial membrane oxygenation (VA-ECMO) support is controversial. Aim of this study has been to report the experience of seven LVAD centers. Methods: Data of LVAD patients (2010–2017) at seven European institutions were reviewed. The only inclusion criteria was VA-ECMO before LVAD placement. Patients’ characteristics, intraoperative variables and postoperative course were analyzed thus eventually identifying predictors of mortality. Results: A total of 154 continuous flow LVAD patients (mean age 53.1 ± 12 years; 84% male) were identified. The VA-ECMO cannulation was peripheral in 92% of patients and 37% had received cardiopulmonary resuscitation prior to VA-ECMO implantation. Mean VA-ECMO duration prior to LVAD implantation was 7.1 ± 7 days. Cardiopulmonary bypass was adopted in 64% of patients for LVAD implantation. Major postoperative complications included right heart failure requiring temporary right ventricular device (RVAD) support (47%), bleeding requiring rethoracotomy (20%), respiratory failure (54%), renal failure (50%) and hepatic failure (31%). Thirty-day and 1-year survival was 84 and 62%, respectively. At univariate analysis age, lactate level, pH, white blood cells (WBC) count, pre-LVAD dialysis and Model for End-stage Liver Disease eXcluding INR (MELD-XI) score before implant were significant. Multivariate regression analysis identified pre-LVAD MELD-XI (OR 1,250, 95% CI 1,038–1,505; p = 0.019) as the only significant predictor of mortality. Conclusions: The outcome of LVAD patients on VA-ECMO support is limited by the high rate of major adverse events. Preoperative LVAD MELD-XI score seems to identify patients that will clearly not benefit from LVAD implantation.

Prognostic value of selected risk scales in patients with end-stage heart failure

Due to the increasing number of patients placed on waiting lists for orthotopic heart transplantation (OHT), the selection of patients with the highest risk of death has become paramount. This study aimed to evaluate the predictive value of the Model for End-stage Liver Disease eXcluding INR (MELD-XI) and Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) scales in ambulatory patients awaiting OHT and compare them to the Heart Failure Survival Score (HFSS). The study was a retrospective review of 370 adult ambulatory patients with end-stage heart failure, who were added to the OHT waiting list at our institution between 2012 and 2016. The median age of the patients was 54.0 (46.0-60.0) years, and 324 (87.6%) of them were male. The overall one-year mortality was 27.6%. The areas under the curve (AUCs) for the MAGGIC and HFSS scales were comparable: 0.771 (95% confidence interval [CI] 0.720-0.823); sensitivity 77%, specificity 68% vs. 0.781 (95% CI 0.732-0.829); sensitivity 90%, specificity 58%, respectively. The AUC for the MELD-XI scale was higher than that for the HFSS scale: 0.812 (95% CI 0.769-0.856); sensitivity 91%, specificity 63% vs. 0.781 (95% CI 0.732-0.829) sensitivity 90%, specificity 58%, respectively. Our study demonstrated that elevated MELD-XI and MAGGIC scores and lowered HFSS scores were associated with an increased risk of death during one-year follow-up. The prognostic utility of the MELD-XI scoring system was better than that of the HFSS scale, while the MAGGIC scale was comparable to the HFSS.

A New Combined Model for End-Stage Liver Disease Excluding INR (CMELD-XI) Score Better Predicts Pediatric Heart Transplant Outcomes

The Model for end-stage liver disease (MELD) score, derived based on serum creatinine, bilirubin, and INR, was developed to accurately predict the probability of waitlist mortality in patients awaiting a liver transplant. Subsequently, a MELD excluding INR (MELD-XI) score was adapted to predict mortality after heart transplant (HT). Our objective was to devise a new combined scoring model (defined as CMELD-XI, derived by adding the MELD-XI score with independent predictors of 1-year mortality) to accurately predict mortality after pediatric HT (PHT).

Model for End-Stage Liver Disease Excluding INR (MELD-XI) score is associated with hemodynamic impairment and predicts mortality in critically ill patients

PurposeWe aimed (i) to evaluate Model for End-stage Liver Disease excluding INR (MELD-XI) score for prediction of mortality in a cohort of critically ill patients and (ii) to investigate associations of MELD-XI with microcirculation and (iii) to evaluate microcirculation for prediction of mortality in high-risk patients, e.g., with high MELD-XI scores. Methods308 patients were included in our retrospective analysis, a subgroup of the multicenter micro-SOAP-study. Microcirculation was evaluated by Sidestream Dark Field (SDF) imaging. Evaluation of associations with mortality was done by logistic regression analysis, an optimal cut-off was calculated by means of the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points). ResultsPatients with a MELD-XI > 12 points were of similar age (60 ± 1 years vs 62 ± 2 years; p = 0.32), but clinically sicker as mirrored by higher APACHE II scores (20 ± 1 vs 16 ± 1; p < 0.001). In the MELD-XI > 12 cohort in-hospital mortality was significantly higher compared to the MELD ≤ 12 group (48% vs 24%%; HR 2.98 95%CI 1.76–5.04; p = 0.003) and MELD-XI score was associated with mortality even after correction for relevant clinical confounders (HR 1.04 95%CI 1.01–1.07; p = 0.004) There were no associations between MELD-XI and parameters of microvascular perfusion. ConclusionsMELD-XI is associated with in-hospital mortality and constitutes a useful tool for risk stratification in intensive care medicine. Interestingly, there were no associations between MELD-XI and microcirculation. Possibly parameters of the microcirculation present an online tool of hemodynamic assessment while MELD-XI presents an assessment of already established organ failure.

Model for End-stage Liver Disease excluding INR (MELD-XI) score in critically ill patients: Easily available and of prognostic relevance.

PurposeMELD-XI, an adapted version of Model for End-stage Liver Disease (MELD) score excluding INR, was reported to predict outcomes e.g. in patients with acute heart failure. We aimed to evaluate MELD-XI in critically ill patients admitted to an intensive care unit (ICU) for prognostic relevance.MethodsA total of 4381 medical patients (66±14 years, 2862 male) admitted to a German ICU between 2004 and 2009 were included and retrospectively investigated. Admission diagnoses were e.g. myocardial infarction (n = 2034), sepsis (n = 694) and heart failure (n = 688). We divided our patients in two cohorts basing on their MELD-XI score and evaluated the MELD-XI score for its prognostic relevance regarding short-term and long-term survival. Optimal cut-offs were calculated by means of the Youden-Index.ResultsPatients with a MELD-XI score >12 had pronounced laboratory signs of organ failure and more comorbidities.MELD-XI >12 was associated with an increase in short-term (27% vs 6%; HR 4.82, 95%CI 3.93–5.93; p<0.001) and long-term (HR 3.69, 95%CI 3.20–4.25; p<0.001) mortality. In a univariate Cox regression analysis for all patients MELD-XI was associated with increased long-term mortality (changes per score point: HR 1.06, 95%CI 1.05–1.07; p<0.001) and remained to be associated with increased mortality after correction in a multivariate regression analysis for renal failure, liver failure, lactate concentration, blood glucose concentration, oxygenation and white blood count (HR 1.04, 95%CI 1.03–1.06; p<0.001). Optimal cut-off for the overall cohort was 11 and varied remarkably depending on the admission diagnosis: myocardial infarction (9), pulmonary embolism (9), cardiopulmonary resuscitation (17) and pneumonia (17). We performed ROC-analysis and compared the AUC: SAPS2 (0.78, 95%CI 0.76–0.80; p<0.0001) and APACHE (0.76, 95%CI 0.74–0.78; p<0.003) score were superior to MELD-XI (0.71, 95%CI 0.68–0.73) for prediction of mortality.ConclusionsThe easily calculable MELD-XI score is a robust and reliable tool to predict both intra-ICU and long-term mortality in critically ill medical patients admitted to an ICU. Optimal cut-off values for MELD-XI scores seem to depend on the primary disease and need to be validated in future prospective studies. Compared to SAPS2 and APACHE score, MELD-XI lacks precision but might have comparable and even additive value, as it is easily available and independent of subjective values.

MELD-XI Score Predicts Early Mortality in Patients After Heart Transplantation

The aim of this study was to determine the utility of the Model for End-Stage Liver Disease Excluding INR (MELD-XI) in predicting early outcomes (30 days and 1 year) and late outcomes (5 years) in patients after orthotopic heart transplantation (OHT). The United Network for Organ Sharing database was queried for all adult patients (aged ≥ 18 years) undergoing OHT from 2000 to 2012. A MELD-XI was calculated and the population stratified into score quartiles. Early and late survivals were compared among the MELD-XI cohorts. Multivariable Cox proportional hazards models were constructed to determine the capacity of MELD-XI (when modeled both as a categoric and a continuous variable) to predict 30-day, 1-year, and 5-year mortality. Conditional models were also designed to determine the effect of early mortality on long-term survival. A total of 22,597 patients were included for analysis. The MELD-XI cutoff scores were established as follows: low (≤ 10.5), low-intermediate (10.6 to 12.6), intermediate-high (12.7 to 16.4), and high (>16.4). The high MELD-XI cohort experienced statistically worse 30-day, 1-year, and 5-year unconditional survivals when compared with patients with low scores (p < 0.001). Similarly, a high MELD-XI score was also predictive of early and late mortality (p < 0.001) after risk adjustment. There was, however, no difference in 5-year survival between the high score and low score cohorts after accounting for 1-year deaths. Subanalysis of patients bridged to transplant with a continuous-flow left ventricular assist device demonstrated similar findings. This is the first known study to examine the relationship between a high MELD-XI score and outcomes in patients after OHT. Patients with hepatic or renal dysfunction before OHT should be closely monitored and aggressively optimized as early mortality appears to drive long-term outcomes.

(147) - MELD-XI Score Predicts Early and Late Mortality in Patients Following Heart Transplantation

Purpose: The Model for End-stage Liver Disease eXcluding INR (MELD-XI) score has been validated as an accurate predictor of outcomes in heart failure patients, but its utility in orthotopic heart transplant (OHT) recipients is unknown. Accordingly, we sought to determine the risk-adjusted influence of an elevated MELD-XI score on early and late mortality following OHT. Methods: The United Network for Organ Sharing database was queried for adult (> 18 years) patients undergoing OHT between 2002 and 2012. A MELD-XI score (incorporating serum creatinine and bilirubin) was calculated. Stratification into “high” and “low” MELD-XI cohorts based on a previously established threshold score of 17 was performed. Patient specific characteristics, intraoperative variables and postoperative outcomes were compared between the two cohorts. Thirty-day, 1-year and 5-year multivariable Cox hazard regression models were constructed to determine the risk-adjusted impact of a “high” MELD-XI score on mortality. Kaplan Meier estimates were utilized to compare unadjusted survival. Results: Of the 27,126 patients that met criteria for inclusion, 22% (6,048) had MELD-XI scores > 17. Thirty-day (p< 0.001), 1-year (p< 0.001) and 5-year (p< 0.001) survival was statistically different between the score cohorts. Additionally, a “high” MELD-XI score was an independent predictor of 30-day (HR: 1.75, CI: 1.52-2.02; p< 0.001), 1-year (HR: 1.62, CI: 1.48-1.77; p< 0.001) and 5-year (HR: 1.33, CI: 1.25-1.43; p< 0.001) mortality after adjustment with a combination of recipient, donor and transplant specific variables. This cohort also experienced an increased incidence of postoperative renal failure (11.7% v. 6.5%; p< 0.001) and stroke (3.3% v. 2.2%; p< 0.001). Conclusion: This is the largest known study demonstrating the unique application of the MELD-XI scoring system in predicting early and late mortality in patients following OHT. The MELD-XI provides another preoperative metric to improve patient selection and, thus, optimize organ allocation.