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

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.

Model for End-Stage Liver Disease (MELD) Does Not Predict Mortality after Veno-Arterial Extracorporeal Membrane Oxygenation Support

Purpose The Model of End-Stage Liver Disease (MELD) score incorporates measures of kidney and liver dysfunction . MELD score has been shown to predict mortality in patients with advanced heart failure or cardiogenic shock (CS). Prior small single-center studies have shown that MELD score predicts mortality in patients supported with Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). The Purpose of our was to reassess the role of MELD score predicting Mortality After (VA-ECMO). Methods We reviewed 105 consecutive patients with (CS) who received VA-ECMO between 8/2014 and 6/2018 in our hospital. We calculated MELD, MELD excluding INR (MELDXI), MELD with sodium -MELDNa- (calculated at a mean of 7 hours prior to VA-ECMO initiation), and SAVE score. We identified the association between each score and short-term mortality using logistic regression and Kaplan-Meier with Cox proportional hazard models . Results Our patient had Mean age was 57.1 ± 13.8 years and 32% female. Mean MELD score was 19.5 ± 8.3, MELDXI 18.9 ± 7.1, MELDNa 20.5 ± 8.3, SAVE -8.6 ± 6.5. Inpatient mortality was 68%. SAVE score was associated with short-term (OR 0.91 per 1 unit, 95% CI: 0.84-0.98, P=0.011) and long-term mortality (HR 0.95, 95% CI: 0.91-0.98, P=0.002) (Figure 1). There was no association between MELD (OR 1.02, 95% CI: 0.97-1.08, P=0.41), MELDXI (OR 1.01, 95% CI: 0.95-1.07, P=0.86), or MELDNa (OR 1.02, 95% CI: 0.97-1.08, P=0.41), with inpatient mortality. MELD (OR 1.07, 1.01-1.13, P=0.02), MELDXI (OR 1.12 [1.05-1.20], P=0.001) and MELDNa (OR 1.06, 95% CI: 1.01-1.12, P=0.03) were all associated with need for hemodialysis after ECMO. Conclusion In this single-center study of patients with VA ECMO, neither MELD, nor MELDXI or MELDNa, were associated with short-term or long-term mortality. SAVE score was able to modestly predict inpatient mortality. Further studies are needed to delineate the impact of bystander organ dysfunction to predict mortality in patients supported with VA-ECMO.

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.

Prospective Evaluation of LVAD Risk Scores’ Capacity to Predict Cardiopulmonary Exercise Parameters

Purpose Risk scores for left ventricular assist device (LVAD) therapy are known to predict morbidity and adverse events in addition to mortality. This study evaluates the capacity of popular LVAD risk scores to predict cardiopulmonary exercise parameters. Methods Adult patients undergoing continuous flow LVAD implantation were prospectively followed. 5 risk scores were calculated before implantation: Model for End Stage Liver Disease (MELD), MELD excluding INR (MELD-XI), MELD including sodium (MELD-Na), HeartMate2 Risk Score (HMRS) and Destination Therapy Risk Score (DTRS). Cardiopulmonary exercise tests (CPET) were performed before and after implantation; peak oxygen consumption (vO 2max), the lowest vE/vCO2 ratio and exercise time were measured. Results 92 patients were implanted during the study period (Mortality Cohort) and 30 patients out of these completed pre- and post-implantation CPETs (CPET Cohort). Mean pre- and post-implantation CPET dates were 29±10 days before and 109±5 days following implantation. CPET parameters significantly improved after implantation (p . In multivariate analysis , all risk scores independently predicted 90-day mortality; MELD, MELD-XI, MELD-Na and HMRS independently predicted both pre- and post-implantation vE/vCO 2 while MELD-Na and HMRS were also independent predictors of pre- and post-implantation vO2max respectively (Table 2). Conclusion Four pre-implantation LVAD risk scores (HMRS, MELD, MELD-Na and MELD-XI) independently predict important cardiopulmonary exercise parameters such as vE/vCO2 and vO2max in addition to mortality in LVAD therapy.

Impact of 30 Day Readmission After Left Ventricular Assist Device Implantation.

Early readmission (within 30 days) after left ventricular assist device (LVAD) implantation might be a marker for increased mortality. We retrospectively reviewed the records of 277 adults who underwent continuous-flow LVAD implantation from 2005 through 2015 at our institution. The baseline characteristics of patients who were (versus were not) readmitted within 30 days after LVAD implantation were compared. To assess the impact of 30 day readmission on long-term survival, we used multivariate Cox regression. We also compared the cardiac transplant rate between the two groups. Of the 277 patients, 217 (78.3%) underwent LVAD implantation as a bridge-to-transplant; 76 (27.4%) of the 277 were readmitted within 30 days. The most common reason for readmission was volume overload (23.6%), followed by gastrointestinal bleeding (15.8%). Male gender, previous smoking, a higher baseline creatinine level, higher Model for End Stage Liver Disease Excluding INR (MELD-XI) score, and postoperative gastrointestinal bleeding or stroke were each associated with 30 day readmission. In our final multivariate model, increased mortality was also associated with 30 day readmission (hazard ratio, 1.60; 95% confidence interval, 1.1-2.5). Among the 217 bridge-to-transplant patients, the cardiac transplant rate was similar between the two groups: 18.7 transplants per patient-year among those who were readmitted within 30 days versus 19.7 transplants per patient-year among those who were not (p = 0.26). Among our study patients, 30 day readmission after LVAD implantation was frequent and was associated with increased mortality. It is currently unclear whether the general health of those patients was a factor and whether efforts to reduce 30 day readmission would favorably affect longer-term patient outcomes.

600.24 Transcatheter versus Surgical Aortic Valve Replacement in Patients with Chronic Liver Disease: A Meta-analysis

Cirrhosis increases cardiac surgical risk with a 30-day mortality of 9–52% in Child-Pugh class A and C, respectively. A higher Model for End-stage Liver Disease excluding International normalized ratio (MELD-XI) score is associated with higher mortality following transcatheter aortic valve

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.

Assessment of Advanced Liver Fibrosis and the Risk for Hepatic Decompensation in Patients With Congestive Hepatopathy.

Congestive hepatopathy (CH) arises from chronically elevated right-sided heart pressures transmitted to the liver by passive venous congestion. Over time, CH can lead to hepatic bridging fibrosis, decompensated cirrhosis, and hepatocellular carcinoma. Currently, there are no evidence-based guidelines to direct appropriate screening or management of patients with CH, partly because of the inability of current clinical tools (serum tests, imaging studies, liver stiffness measurements, and liver biopsy) to accurately estimate hepatic fibrosis or the risk for hepatic decompensation. The Model for End-Stage Liver Disease excluding international normalized ratio (MELD-XI) score is the only validated serum-based test to predict clinical outcomes in CH. Noninvasive liver stiffness measurements are proving to be of minimal utility as all patients with CH have elevated values that currently cannot differentiate between congestion and fibrosis. In addition, fibrosis staging by liver biopsy is difficult to standardize because of heterogeneous collagen deposition in CH. Moreover, liver biopsy results have little predictive value for post-heart transplant hepatic outcomes in patients with CH. Evaluating liver nodules and masses is also complicated in CH as the finding of delayed venous washout in nodules is not specific for hepatocellular carcinoma in the background of a congested liver, and these lesions may require biopsy to confirm the diagnosis. The lack of effective clinical tools for predicting liver fibrosis and liver function suggests the need for the development of novel biomarkers in patients with CH to assist in the management of this complicated disease. (Hepatology 2018; 00:000-000).

Preoperative MELD-XI is not Associated with Mortality after LVAD

Background Kidney and liver dysfunction are common in patients with advanced heart failure undergoing left ventricular assistant device (LVAD) implantation. We have previously shown that Model of End-Stage Liver Disease excluding INR (MELD-XI) scores can predict poor outcomes after heart transplantation. Whether MELD-XI predicts outcomes after LVAD implantation is not well understood. Methods All patients who underwent LVAD implantation at a tertiary referral center (2007-2017) were included and preoperative MELD-XI was calculated. Cox proportional hazard models and Kaplan Meier method were used to describe association with overall post-implant mortality. Penalized smoothed splines were used to visualize the association between continuous MELDXI and mortality. Results A total of 94 patients were included. Mean age was 60±13 years, 78% males, 64% Caucasian, 76% had the HeartMate II. Median MELD-XI was 12.4(9.9-15.9). At a median follow-up of 2.8 years, 31 patients died. There was no difference between patients with MELD-XI >12.4 and MELD-XI ≤12.4 in overall mortality ( P =0.14), figure (panel A). There was no association between continuous MELD-XI and mortality (HR 1.04; 95% CI: 0.96-1.13, P =0.32), figure (panel B). Conclusion Our findings showed that MELD-XI is not associated with mortality after LVAD implantation. These findings need to be validated in a larger group registry to identify best bridging strategy in patients with advanced heart failure and combined kidney-liver dysfunction.

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

BackgroundThe Model for End‐stage Liver Disease excluding international normalized ratio (MELD‐XI) score and the modified MELD score with albumin replacing international normalized ratio (MELD‐Albumin) score, which reflect both liver and renal function, have been reported as predictors of adverse events in liver and heart disease. Nonetheless, their prognostic value in patients undergoing tricuspid annuloplasty has not been addressed.Methods and ResultsA total of 394 patients who underwent tricuspid annuloplasty were evaluated. Baseline clinical, laboratory, and echocardiographic parameters were recorded. Adverse outcome was defined as the occurrence of heart failure requiring admission or all‐cause mortality. Patients who underwent tricuspid annuloplasty had a high prevalence of preoperative hepatorenal dysfunction that was more common in patients with severe tricuspid regurgitation than those with mild to moderate tricuspid regurgitation. The MELD‐XI and MELD‐Albumin scores were excellent predictors of 1‐year adverse outcome (area under the curve: 0.69 and 0.75, respectively). Kaplan–Meier survival curve demonstrated that a high score on MELD‐XI (≥12.0) and MELD‐Albumin (≥10.7) was associated with an increased risk of adverse events. During a median follow‐up of 40 months, both MELD‐XI and MELD‐Albumin scores were significantly associated with adverse outcome, even after adjusting for potential confounding factors. Significant improvement of hepatorenal function at 1 year postoperation was noted only in patients who had no adverse events, not in those who experienced an adverse outcome.ConclusionsBoth MELD‐XI score and MELD‐Albumin score can provide useful information to predict adverse outcome in patients undergoing tricuspid annuloplasty. The present study supports monitoring of modified MELD score to improve preoperative risk stratification of these patients.

Prognostic utility of MELD-XI in adult congenital heart disease patients undergoing cardiac transplantation.

Model of End-Stage Liver Disease eXcluding INR (MELD-XI) at cardiac transplant has demonstrated prognostic survival utility, but has not been specifically validated in adult congenital heart disease (ACHD) in a registry study. Adults undergoing first-time orthotopic heart transplant from 2005 to 2015 in the United Network for Organ Sharing (UNOS) registry were examined in parallel: ACHD (n=543), ischemic-dilated cardiomyopathy (IDCM, n=6954) and valvular heart disease (VHD, n=355). Our primary endpoint was a composite of death, graft failure, and retransplantation assessed at 3months (early), and those with freedom from early endpoint were reassessed at 5years (late). Interactions between hepatorenal indices and waitlist time were examined. Secondary outcomes relating to long-term morbidity were assessed at late endpoint. Freedom from endpoint analysis in ACHD at clinically relevant endpoints was also conducted. Model of End-Stage Liver Disease eXcluding INR score at transplant associated with an increased risk of early endpoint in all cohorts. At late endpoint, bilirubin level associated with increased risk uniquely in ACHD. Model of End-Stage Liver Disease eXcluding INR holds prognostic application to ACHD in early time points and demonstrates unique waitlist interactions. Transplant bilirubin level may hold significance in long-term risk stratification of the ACHD population. Time on waitlist is an important consideration to contextualize these values.

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).

Risk prediction in infective endocarditis by modified MELD-XI score.

The suitability of the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score to predict adverse outcomes in infective endocarditis (IE) patients remains uncertain. This study was performed to explore the prognostic value of the MELD-XI score and modified MELD-XI score for patients with IE. A total of 858 patients with IE were consecutively enrolled and classified into two groups: MELD-XI ≤ 10 (n = 588) and MELD-XI > 10 (n = 270). Multivariate analysis was performed to determine risk factors independent of MELD-XI score. Higher MELD-XI score was associated with higher in-hospital mortality (15.6 vs. 4.8%, p < 0.001) and major adverse clinical events (33.3 vs. 18.4%, p < 0.001). MELD-XI score was an independent predictor of in-hospital death (odds ratio [OR] = 1.06, 95% CI, 1.02-1.10, p = 0.005). Based on a multivariate analysis, NYHA class III or IV (3 points), C-reactive protein > 9.5mg/L (4 points), and non-surgical treatment (6 points) were added to MELD-XI score. Modified MELD-XI score produced higher predictive power than previous (AUC 0.823 vs. 0.701, p < 0.001). The cumulative incidence of long-term mortality (median 29months) was significantly higher in patients with modified MELD-XI score > 13 than those without (log-rank = 25.30, p < 0.001). Modified MELD-XI score was independently associated with long-term mortality (hazard ratio = 1.08, 95% CI, 1.04-1.12, p < 0.001). MELD-XI score could be used as a risk assessment toolin IE. Furthermore, modified MELD-XI score remained simple and more effective in predicting poor prognosis.

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.

Temporal changes in liver stiffness after Fontan operation: Results of serial magnetic resonance elastography

BackgroundThe relationship between temporal progression of magnetic resonance elastography derived liver stiffness (MRE-LS) and progression of Fontan associated liver disease (FALD) is unknown. To assess this relationship, we hypothesized that progression of MRE-LS correlated with progression FALD severity and clinical outcomes. MethodsRetrospective review of Fontan patients who had >1 liver MRE, 2010–2016. Annual change in MRE-LS was the quotient of the difference between baseline and subsequent MRE-LS, and the interval between scans. Results22 patients were enrolled; median age 29(19–38) years, 14 (64%) males and 10 (46%) with atriopulmonary Fontan. Baseline and subsequent MRE-LS values were 5.4 ± 1.1 kPa and 5.8 ± 0.9 kPa" for clarity, interval between scans was 25 ± 5 months, and annual change in MRE-LS was 0.3 ± 0.2 kPa. Temporal change in MRE-LS correlated with temporal changes in model for end-stage liver disease (MELD) score (r = 0.84, p < 0.001) and model for end-stage liver disease excluding international normalized ratio (MELD-XI) score (r = 0.75, p = 0.001). The study cohort was divided into 2 groups using the mean annual change in MRE-LS as the cut point. Groups A and B comprised of patients with annual increase in MRE-LS ≥0.3 kPa (n = 6) and <0.3 kPa (n = 16) respectively. Composite adverse event endpoint (death, heart–liver transplant listing, palliative care, hospitalization, paracentesis) was more common in Group A (4 of 6, 67%) compared to Group B (3 of 16, 19%), p = 0.13 although this did not reach statistical significance due to small sample size. ConclusionsProgression of MRE-LS correlated with clinical deterioration as measured by worsening liver disease severity scores and the occurrence of adverse events.

Extracorporeal membrane oxygenation as a direct bridge to heart transplantation in adults

ObjectivesVenoarterial extracorporeal membrane oxygenation (ECMO) use as a bridge to transplant is extremely infrequent in adults. We investigated patient outcomes of the use of ECMO as bridge to transplant. MethodsUnited Network of Organ Sharing provided de-identified patient-level data. Between 2003 and 2016, 25,168 adult recipients were identified. Of these, 107 (0.4%) were bridged with ECMO and 6148 (24.4%) were bridged with a continuous-flow left ventricular assist device. ResultsPatients in ECMO group were younger, more likely to have severely disabled functional status, shorter waitlist time, and were more frequently mechanically ventilated than were patients in the continuous-flow left ventricular assist device group. Kaplan-Meier analysis demonstrated estimated posttransplant survival of 73.1% versus 93.1% at 90 days (P < .001) and 67.4% versus 82.4% at 3 years (P < .001) in ECMO and continuous-flow left ventricular assist device groups, respectively. Analysis of a propensity-matched cohort still demonstrated a lower survival in ECMO group at 90 days (74.8% vs 88.8%; P = .025) and 3 years (69.3% vs 82.2%; P = .054). Among the ECMO patients, multivariable logistic and Cox regression analyses showed model for end-stage liver disease excluding international normalized ratio (MELD-XI) score to be the sole contributor to both 90-day (odds ratio, 1.94; 95% confidence interval, 1.00-3.76; P = .050) and 3-year mortality (hazard ratio, 1.47; 95% confidence interval, 1.16-1.88; P = .002). ECMO-supported patients with a high MELD-XI score (>17) were associated with poor posttransplant survival compared with those with a low MELD-XI score (<13) (90 day, 54.4% vs 85.0% [P < .001] and 3 year, 49.5% vs 73.5% [P < .001]). ConclusionsBridge to transplant with ECMO was associated with increased early/mid-term mortality, especially in patients with a high MELD-XI score who demonstrated > 50% 3-year mortality. These findings may help to inform future organ allocation policies.

P1489Prognostic value of the combination of simple risk index and model of end-stage liver disease excluding INR (MELD-XI) scoring system in patients admitted for acute decompensated heart failure

P1489Prognostic value of the combination of simple risk index and model of end-stage liver disease excluding INR (MELD-XI) scoring system in patients admitted for acute decompensated heart 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.

Abstract 13894: Prediction of Mode of Death by Model of End-Stage Liver Disease Excluding INR (MELD-XI) Scoring System in Patients Admitted for Acute Decompensated Heart Failure With Preserved and Reduced Ejection Fraction; a Comparison With Nonalcoholic Fatty Liver Disease Fibrosis Score

Backgrounds: Cardiohepatic interactions have been a focus of attention among heart failure. A model of end-stage liver disease excluding INR (MELD-XI), a robust scoring system of liver dysfunction, has been shown to provide prognostic information in heart failure patients (pts). Furthermore, it was reported that nonalcoholic fatty liver disease (NAFLD) is a risk factor for cardiovascular disease. There is a difference in mode of death (cardiac vs non-cardiac death) between heart failure with preserved (HFpEF) and reduced ejection fraction (HFrEF). We sought to investigate the prognostic significance of MELD-XI and NAFLD in the prediction of mode of death in pts admitted for acute decompensated heart failure (ADHF), relating to HFpEF and HFrEF. Methods and Results: We studied 303 consecutive ADHF pts (HFrEF[LVEF&lt;50%]; n=163, HFpEF[LVEF≥50%];n=140). MELD-XI score was calculated by the formula: 5.11х ln(bilirubin)+11.79х ln(creatinine)+9.44. NAFLD fibrosis score (NFS) was obtained by the formula: -1.675 + 0.037 х age + 0.094 х BMI + 1.13 х hyperglycemia or diabetes (yes = 1, no = 0) + 0.99 х AST/ALT - 0.013 х platelet ( х 10 9 /L) - 0.66 х albumin. During a follow-up period of 5.1±4.3 yrs, 65 pts had cardiac death and 56 pts had non-cardiac death. At multivariate Cox analysis, MELD-XI score, but not NFS, was significantly associated with cardiac death independently of prior heart failure hospitalization, BMI, systolic blood pressure and serum sodium level, while neither MELD-XI score nor NFS showed the association with non-cardiac death. MELD-XI of 13 was a fair discriminator for cardiac death (AUC 0.737[0.670-0.805]). In both groups with HFrEF and HFpEF, pts with higher MELD-XI score had a significantly higher risk of cardiac death than those with lower MELD-XI score. Conclusion: A MELD-XI scoring system might predict cardiac death but not non-cardiac death in ADHF pts, regardless of HFrEF or HFpEF, although NAFLD fibrosis score did not.