TY - JOUR
T1 - Liver dysfunction as a predictor of outcomes in patients with advanced heart failure requiring ventricular assist device support
T2 - Use of the Model of End-stage Liver Disease (MELD) and MELD eXcluding INR (MELD-XI) scoring system
AU - Yang, Jonathan A.
AU - Kato, Tomoko S.
AU - Shulman, Brittney P.
AU - Takayama, Hiroo
AU - Farr, Maryjane
AU - Jorde, Ulrich P.
AU - Mancini, Donna M.
AU - Naka, Yoshifumi
AU - Schulze, P. Christian
N1 - Funding Information:
This work was supported by grants from the National Heart, Lung and Blood Institute ( K23 HL095742-01 , P30 HL101272-01 , UL1 RR 024156 , HL073029 ) and the Herbert and Florence Irving Scholar Award to Dr Schulze. The authors had full control over the study design, methods used, outcome parameters and results, analysis of data, and production of the written report. This study was funded without assistance from industry sources.
PY - 2012/6
Y1 - 2012/6
N2 - Background: Liver dysfunction increases post-surgical morbidity and mortality. The Model of End-stage Liver Disease (MELD) estimates liver function but can be inaccurate in patients receiving oral anti-coagulation. We evaluated the effect of liver dysfunction on outcomes after ventricular assist device (VAD) implantation and the dynamic changes in liver dysfunction that occur during VAD support. Methods: We retrospectively analyzed 255 patients (147 with pulsatile devices and 108 with continuous-flow devices) who received a long-term VAD between 2000 and 2010. Liver dysfunction was estimated by MELD and MELD-eXcluding INR (MELD-XI), with patients grouped by a score of < 17 or < 17. Primary outcomes were on-VAD, after transplant, and overall survival. Results: MELD and MELD-XI correlated highly (R < 0.901, p < 0.0001) in patients not on oral anti-coagulation. Patients with MELD or MELD-XI < 17 had improved on-VAD and overall survival (p < 0.05) with a higher predictive power for MELD-XI. During VAD support, cholestasis initially worsened but eventually improved. Patients with pre-VAD liver dysfunction who survived to transplant had lower post-transplant survival (p = 0.0193). However, if MELD-XI normalized during VAD support, post-transplant survival improved and was similar to that of patients with low MELD-XI scores. Conclusions: MELD-XI is a viable alternative for assessing liver dysfunction in heart failure patients on oral anti-coagulation. Liver dysfunction is associated with worse survival. However, if MELD-XI improves during VAD support, post-transplant survival is similar to those without prior liver dysfunction, suggesting an important prognostic role. We also found evidence of a transient cholestatic state after LVAD implantation that deserves further examination.
AB - Background: Liver dysfunction increases post-surgical morbidity and mortality. The Model of End-stage Liver Disease (MELD) estimates liver function but can be inaccurate in patients receiving oral anti-coagulation. We evaluated the effect of liver dysfunction on outcomes after ventricular assist device (VAD) implantation and the dynamic changes in liver dysfunction that occur during VAD support. Methods: We retrospectively analyzed 255 patients (147 with pulsatile devices and 108 with continuous-flow devices) who received a long-term VAD between 2000 and 2010. Liver dysfunction was estimated by MELD and MELD-eXcluding INR (MELD-XI), with patients grouped by a score of < 17 or < 17. Primary outcomes were on-VAD, after transplant, and overall survival. Results: MELD and MELD-XI correlated highly (R < 0.901, p < 0.0001) in patients not on oral anti-coagulation. Patients with MELD or MELD-XI < 17 had improved on-VAD and overall survival (p < 0.05) with a higher predictive power for MELD-XI. During VAD support, cholestasis initially worsened but eventually improved. Patients with pre-VAD liver dysfunction who survived to transplant had lower post-transplant survival (p = 0.0193). However, if MELD-XI normalized during VAD support, post-transplant survival improved and was similar to that of patients with low MELD-XI scores. Conclusions: MELD-XI is a viable alternative for assessing liver dysfunction in heart failure patients on oral anti-coagulation. Liver dysfunction is associated with worse survival. However, if MELD-XI improves during VAD support, post-transplant survival is similar to those without prior liver dysfunction, suggesting an important prognostic role. We also found evidence of a transient cholestatic state after LVAD implantation that deserves further examination.
KW - cardiomyopathy
KW - liver dysfunction
KW - risk assessment
KW - transplantation
KW - ventricular assist device
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U2 - 10.1016/j.healun.2012.02.027
DO - 10.1016/j.healun.2012.02.027
M3 - Article
C2 - 22458997
AN - SCOPUS:84862780641
SN - 1053-2498
VL - 31
SP - 601
EP - 610
JO - Journal of Heart and Lung Transplantation
JF - Journal of Heart and Lung Transplantation
IS - 6
ER -