Model For End-stage Liver Disease Excluding International Normalized Ratio Research Articles

The Impact of Pre-Heart Transplantation Blood Transfusion Varies Based on Recipient MELD-XI Score.

Prior studies reveal adverse effects of transfusion on cardiac surgery, but little is known of transfusion impact on heart transplantation. First-time, single-organ adult heart transplant recipients between January 1, 2010, and December 31, 2020, were included, stratified above or below a model for end-stage liver disease excluding international normalized ratio (MELD-XI) score of 9.4, and propensity score matched to their nearest neighbor. A 90 day landmark analysis within each cohort was also performed. Unadjusted analysis showed transfusion recipients, MELD-XI ≥9.4, were more likely to experience post-heart transplantation mortality (Hazard Ratio (HR), 1.352 [95% Confidence Interval (CI), 1.239-1.477], p < 0.001), persisting after adjustment for potential confounders (adjusted HR, 1.211 [95% CI, 1.100-1.335], p < 0.001) and after propensity-score matching (HR, 1.174 [95% CI, 1.045-1.319], p = 0.007). Post-transplant length of stay was longer (25.9 vs. 23.2 days, p < 0.001). Post-transplant dialysis was more common (18.7 vs. 15.9%, p = 0.009). There was no survival difference on 90 day landmarked analysis (p = 0.108). With MELD-XI <9.4, there was slight survival detriment among transfusion recipients on univariable analysis (HR, 1.111 [95% CI, 1.001-1.234], p = 0.049) but not on multivariable analysis (adjusted HR, 1.061 [95% CI, 0.952-1.181], p = 0.285). There was similar survival after propensity-score matching (HR, 1.032 [95% CI, 0.903-1.180], p = 0.642) and on landmark analysis (p = 0.581). Ultimately, transfusion was associated with worse post-heart transplantation outcomes among recipients with a MELD-XI ≥9.4.

The model for end-stage liver disease excluding international normalized ratio (MELD-XI) predicts three-year mortality in patients with advanced heart failure

The model for end-stage liver disease excluding international normalized ratio (MELD-XI) predicts three-year mortality in patients with advanced heart failure

Determinants of Advanced Liver Fibrosis in Adult Patients After Fontan Palliation: Usefulness of Ultrasound Transient Elastography.

Fontan-associated liver disease is an increasing concern. Our aim was to assess prevalence and predictors of advanced liver fibrosis with a specific focus on utility of liver stiffness measurement by ultrasound transient elastography. A total of 97 adult Fontan patients (55% male, median age: 23.1 years, interquartile range [IQR]: 18.7-30.6); 92 (95%) were evaluated with transient elastography, and 50 (52%) underwent transjugular liver biopsy. Advanced liver fibrosis was defined as congestive hepatic fibrosis score 3 or4. Only 4 patients (4%) had liver stiffness values < 10 kilopascal (kPa). Liver-stiffness measurements correlated weakly with peak oxygen uptake on exercise testing and Fontan pressure but not with Model for End-Stage Liver Disease excluding INR (MELD-XI) score or spleen size. Serial follow-up liver stiffness measurements in 73 clinically stable patients showed large variability among individual patients. Advanced liver fibrosis was present in 35 of 50 (70%) patients on liver biopsy and was associated to MELD-XI-Score ≥ 11 and splenomegaly but not to liver-stiffness measurements. Advanced liver fibrosis was not associated with patient age or time since Fontan operation but with younger age at completion of Fontan (3.7 years, IQR: 2.3-6.3 vs 6.8 years; IQR: 3.5-12.1; P= 0.037). In our cohort, advanced liver fibrosis was present in the majority of adult Fontan patients. Liver stiffness as measured by transient elastography was not associated with the degree of liver fibrosis. Because of its high variability on serial measurements, it seems not to be useful for clinical decision making. The unexpected finding that younger age at completion of Fontan was associated with advanced liver fibrosis merits further evaluation.

Utilization of hepatitis C virus infected donors in heart transplant recipients with elevated MELD-XI score.

The advent of direct-acting antivirals has helped to increase the safe utilization of organs from hepatitis C virus positive (HCV+) donors. However, the outcomes of heart transplantation (HT) using an HCV+ donor are unclear in recipients with underlying liver disease represented by an elevated model for end-stage liver disease excluding international normalized ratio (MELD-XI). The United Network of Organ Sharing database was queried from Jan 2016 to Dec 2021. Post-transplant outcomes stratified by recipient MELD-XI score (low<10.37, medium, 10.38-13.39, and high>13.4) was compared between patients with HT from HCV+ (N=792) and patients with HT from HCV-negative donors (N=15,266). The median MELD-XI score was comparable (HCV+, 12.1, vs. HCV-negative, 11.8, p=.37). In the HCV+ group, donors were older (33vs. 31 years, p<.001). Ischemic time of donor hearts (3.48vs. 3.28h, p<.001) and travel distance (250vs. 157 miles, p<.001) were longer in HCV+ group. In the Kaplan Meier analysis with a median follow-up of 750 days, survival was comparable between the two groups (2-year survival, MELD-XI Low: HCV+, 92.4±3.6% vs. HCV-negative, 91.1±.8%, p=.83, Medium: HCV+ 89.2±4.3% vs. HCV-negative, 88.2±1.0%, p=.68, and High: HCV+, 84.9±4.5% vs. HCV-negative, 84.6±1.1%, p=.75) In multivariate Cox hazard models, HCV donors were not associated with mortality in each MELD-XI subgroup (Low: adjusted hazard ratio (aHR), 1.02, p=.94; Medium: aHR, .95, p=.81; and High: aHR, .93, p=.68). Utilization of HCV+ hearts was not associated with an increased risk of adverse outcomes in recipients with an elevated MELD- XI score.

Prognostic impact of the coexistence of hepato-renal dysfunction and frailty in patients with heart failure

BackgroundComplex multi-organ interactions such as coexistence of hepato-renal dysfunction in heart failure (HF) adversely affects patient prognosis. However, the association between liver/kidney dysfunction and frailty and effects of their coexistence on HF prognosis remain unclear. MethodsThis retrospective cohort study included 922 patients with HF (median age, 72 years; interquartile range: 62–79 years). All patients underwent hepato-renal function testing using the model for end-stage liver disease, excluding international normalized ratio (MELD-XI) score and frailty score. Frailty was measured using a composite of four markers: handgrip strength, gait speed, serum albumin, and activities of daily living status, combined into a total frailty score (range 0–12). Patients were assigned to a frailty score <5 (without frailty) or ≥5 (frailty) group. The multivariable logistic regression model was used to analyze the association between MELD-XI score and frailty; the prognostic value of high MELD-XI score and frailty coexistence was investigated. The endpoint was all-cause mortality. ResultsAfter adjusting for covariates and dividing by the median MELD-XI score, the high MELD-XI score group [odds ratio: 1.663, 95 % confidence interval (CI): 1.200–2.304, p = 0.002] was significantly associated with frailty, compared with the low MELD-XI score group. One hundred and fifty deaths occurred during follow-up (median, 2.13 years; interquartile range, 0.93–4.09 years). Patients in the high MELD-XI score/frailty group had a significantly higher mortality risk, even after adjusting for HF severity (hazard ratio: 4.326, 95 % CI: 2.527–7.403, p < 0.001). ConclusionsHepato-renal dysfunction is associated with frailty in patients with HF, which affects patient prognosis. Brief summaryThis study showed that hepato-renal dysfunction in patients with HF, as assessed by the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score, is associated with frailty, even after adjusting for factors involved in the frailty or severity of HF. Additionally, high MELD-XI score combined with frailty is associated with a poorer prognosis. These results suggest that hepato-renal dysfunction and frailty can be used for risk stratification in patients with HF.

Impact of Preoperative Liver Function on Short-Term HeartMate 3 Outcomes

Although left ventricular assist device (LVAD) therapy is associated with improved survival, the impact of preoperative liver function on short-term outcomes is unclear. We conducted a retrospective review of all primary HeartMate 3 LVAD implants at a single center. Composite metrics of hepatic function including the model for end-stage liver disease (MELD), the MELD with sodium, and the MELD excluding international normalized ratio (MELD-XI) were evaluated. Receiver operator characteristic curves were compared to determine which equation was most predictive of 1-year survival. Primary stratification was based on MELD-XI tertiles. Secondary stratification was based on hypoalbuminemia (<3.0 mg/100 ml). A total of 94 patients underwent primary LVAD implantation from 2017 to 2022. MELD-XI and hypoalbuminemia were most associated with 1-year outcomes. When stratified by MELD tertiles, higher MELD was strongly associated with decreased 30 days (100.00% vs 100.00% vs 90.32%, p=0.04), 1-year (93.00% vs 93.32% vs 69.79%, p=0.01), and 2-year survival (93.00% vs 83.21% vs 69.79%, p=0.04). In addition, while hypoalbuminemia was associated with similar 30 days (97.87% vs 95.74%, p=0.56) survival, it was associated with a significant decrease in 1-year (92.93% vs 77.92%, p=0.03) and 2-year survival (92.93% vs 68.89%, p <0.01). These results persisted on multivariable analysis for both MELD-XI score (p=0.04) and hypoalbuminemia (p=0.04). In conclusion, this is the first study to demonstrate that preoperative MELD-XI score and serum albumin levels are associated with short-term HeartMate 3 outcomes.

Prognostic importance of improving hepatorenal function during hospitalization in acute decompensated heart failure.

The Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) is an established scoring system that reflects hepatorenal function. However, little is known about the prognostic value of changes in MELD-XI score during hospitalization in acute decompensated heart failure (ADHF). We prospectively analysed 536 patients admitted for ADHF between January 2018 and December 2019. In the MELD-XI, 9.44 is the lowest possible score and considered to be normal, and values above 9.44 are classified as high. We calculated MELD-XI scores at admission and discharge and used them to divide patients into four groups depending on whether the score was high (>9.44) or normal (9.44) at each time point as follows: normal score at both measurements (persistently normal group, n=99), high score at admission and normal score at discharge (high-to-normal group, n=108), normal score at admission and high score at discharge (normal-to-high group, n=24), and high score at both measurements (persistently high group, n=305). The persistently high group had higher blood urea nitrogen, creatinine, and N-terminal pro-brain natriuretic peptide levels at both admission and discharge and significantly higher left ventricular end-diastolic, left atrial, right ventricular end-diastolic, and maximal inferior vena cava diameters at discharge. During the median follow-up period of 369days (Q1, Q3: 97, 576), 231 (43.1%) patients reached the primary endpoint (a composite of all-cause death or re-hospitalization for heart failure). The Kaplan-Meier analysis revealed a significantly higher composite event rate in the persistently high group than in the persistently normal and high-to-normal groups (log-rank test, P<0.001). Compared with the persistently high group, the high-to-normal group remained significantly associated with lower composite event risk after multivariate adjustment (hazard ratio, 0.30; 95% CI, 0.12-0.69; P=0.004). Our study suggests that changes in hepatorenal function during hospitalization are associated with the severity of heart failure and systemic congestion and that they provide useful information for predicting clinical outcomes in patients with ADHF.

Prognostic value of modified model for end-stage liver disease scores in patients with significant tricuspid regurgitation.

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 analyse the prognostic value of MELD-XI and MELD-Albumin scores in patients with significant TR. 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 (95% CI), 0.237 (0.138-0.323)]; MELD-Albumin score: net reclassification index (95% CI), 0.220 (0.122-0.302)}. Results were similar in clinically meaningful subgroups, including but not limited to patients under medical treatment and those with normal left ventricular ejection fraction. Models including modified MELD scores were established for prognostic evaluation of significant TR. Both MELD-XI and MELD-Albumin scores provided incremental prognostic information and could play important roles in risk assessment in patients with significant TR.

Fontan-associated liver disease.

Fontan-associated liver disease.

Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy.

AimsMulti‐organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End‐stage Liver Disease eXcluding International normalized ratio (MELD‐XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD‐XI score and the long‐term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated.Methods and resultsClinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD‐XI score: first tertile (MELD‐XI = 9.44, n = 95), second tertile (9.44 < MELD‐XI < 13.4, n = 94), and third tertile (MELD‐XI ≥ 13.4, n = 94). The primary endpoint was all‐cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N‐terminal pro‐brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow‐up of 30 months (inter‐quartile range, 9–67), 105 patients (37.1%) died. Kaplan–Meier analysis revealed that patients with a higher MELD‐XI score had a greater risk of all‐cause mortality (log‐rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD‐XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00–1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01–1.09, P = 0.005, respectively). A higher MELD‐XI score was associated with a greater risk of all‐cause mortality than a lower MELD‐XI score regardless of whether a pacemaker or defibrillator was implanted (log‐rank test: P = 0.010 and P < 0.001, respectively).ConclusionsImpaired hepatorenal function assessed by the MELD‐XI score was associated with older age, higher prevalence of multiple co‐morbidities, severity of HF, lower CRT response rates, and subsequent all‐cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD‐XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.

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.

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

BackgroundHepatorenal 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.MethodsIn 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.ResultsOf 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).ConclusionsThe 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.

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.

Associations of severity of liver damages with physical function and prognosis in patients with heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Heart failure (HF) and liver dysfunction often coexist because of complex cardiohepatic interactions, which adversely affects prognosis. However, the association between liver dysfunction and physical dysfunction, and between coexistence of both and prognosis in HF patients remains unclear. Purpose We evaluated the associations of severity of liver damage and physical function and prognosis in patients with HF. Methods The study population consisted of 895 patients with HF (mean age, 69.4 ± 14.2 years) who underwent liver function test using model for end-stage liver disease excluding international normalized ratio (MELD-XI) score and physical function test (grip strength, leg strength, gait speed, and 6-minute walking distance [6MWD]). The associations between MELD-XI score and physical function were assessed by multivariate linear regression model analysis. Moreover, we investigated the prognostic value of coexistence of liver dysfunction and physical dysfunction. The endpoint was all-cause mortality. Results After adjusting for covariates, MELD-XI score was independently associated with lower grip strength, leg strength, gait speed, and 6MWD (P &amp;lt; 0.001). In addition, hierarchical multivariate linear regression analysis revealed that adding MELD-XI scores or BNP explained additional variance in the physical function measures. The MELD-XI score added to the clinical model was significantly more predictive of physical function (grip strength, change in F: 27.105, P &amp;lt; 0.001; leg strength, change in F: 33.980, P &amp;lt; 0.001; gait speed, change in F: 22.826, P &amp;lt; 0.001; 6MWD, change in F: 59.193, P &amp;lt; 0.001) than BNP added to the clinical model. Eighty-six deaths occurred over a median follow-up period of 1.67 years (interquartile range: 0.62 – 3.04). Patients with high MELD-XI score and reduced physical function were found to have significantly higher mortality risk even after adjusting for several covariates (grip strength, hazard ratio [HR] = 3.80 [95% confidence interval (CI) = 2.04 – 7.08], P &amp;lt; 0.001; leg strength, HR = 4.65 [95% CI = 2.47 - 8.75], P &amp;lt; 0.001 and gait speed, HR = 2.49 [95% CI = 1.43 - 4.33], P = 0.001; 6MWD, HR = 5.48 [95% CI = 2.88 - 10.41], P &amp;lt; 0.001). Conclusions Liver dysfunction was correlated with reduced physical function. Moreover, the coexistence of lower physical function and liver dysfunction considerably affected prognosis in patients with HF. Abstract Figure. Kaplan–Meier survival curves

Evaluation of Laboratory Predictors for In-Hospital Mortality in Infective Endocarditis and Negative Blood Culture Pattern Characteristics.

Objective: This study aimed to identify possible differences between blood culture-negative and blood culture-positive groups of infective endocarditis (IE), and explore the associations between biological parameters and in-hospital mortality. Methods: This was a retrospective study of patients hospitalized for IE between 2007 and 2017. Epidemiological, clinical and paraclinical characteristics, by blood culture-negative and positive groups, were collected. The best predictors of in-hospital mortality based on the receiver-operating characteristic (ROC) analysis and AUC (area under the curve) results were identified. Results: A total of 126 IE patients were included, 54% with negative blood cultures at admission. Overall, the in-hospital mortality was 28.6%, higher in the blood culture-negative than positive group (17.5% vs. 11.1%, p = 0.207). A significant increase in the Model for End-Stage Liver Disease Excluding International Normalized Ratio (MELD-XI) score was observed in the blood culture-negative group (p = 0.004), but no baseline characteristics differed between the groups. The best laboratory predictors of in-hospital death in the total study group were the neutrophil count (AUC = 0.824), white blood cell count (AUC = 0.724) and MELD-XI score (AUC = 0.700). Conclusion: Classic laboratory parameters, such as the white blood cell count and neutrophil count, were associated with in-hospital mortality in infective endocarditis. In addition, MELD-XI was a good predictor of in-hospital death.

Thinking fast and slow: lactate and MELD-XI (model for end-stage liver disease excluding INR) are useful for estimating mortality after cardiopulmonary resuscitation.

Intensivists keep getting challenged with prognostication after cardiopulmonary resuscitation (CPR). The model for end-stage liver disease, excluding INR (MELD-XI) Score has proven valuable for assessing illness severity. Serum lactate is a readily available and established indicator of general stress and tissue hypoxia. We aimed to evaluate the prognostic value of MELD-XI combined with serum lactate in patients after CPR. A retrospective analysis on 106 patients after CPR was performed. Multivariable Cox regression was performed to evaluate associations with 30-day mortality and neurological outcome by means of cerebral performance category (CPC). An optimal cut-off was calculated by means of the Youden Index. Patients were then divided into subgroups based on the optimal cut-offs for MELD-XI and serum lactate. MELD-XI and lactate were independently associated with mortality. The respective cut-offs were MELD-XI>12 and lactate ≥2.5 mmol/L. Patients were split into three groups: lactate <2.5 mmol/L and MELD-XI≤12 (low-risk; N.=32), lactate ≥2.5 mmol/L or MELD-XI>12 (medium-risk; N.=39), and lactate ≥2.5 mmol/L and MELD-XI >12 (high-risk; N.=33). The mortality rates were 6%, 26% and 61% in the low, medium and high-risk group. This combined model yielded in the highest predictive abilities (AUC=0.78 95%CI: 0.68-0.85; P=0.03 vs. AUC=0.66 for SOFA Score). Worse neurological outcome (CPC 3 or 4) was more common in the medium and high-risk group (6.25%, 10.3% and 9.1%). The combination of MELD-XI and lactate concentration at ICU admission was superior to the more complex SOFA Score for prediction of mortality after CPR.