Liver dysfunction as a predictor of outcomes in patients with advanced heart failure requiring ventricular assist device support

Use of the Model of End-stage Liver Disease (MELD) and MELD eXcluding INR (MELD-XI) scoring system

Jonathan A. Yang, Tomoko S. Kato, Brittney P. Shulman, Hiroo Takayama, Maryjane Farr, Ulrich P. Jorde, Donna M. Mancini, Yoshifumi Naka, P. Christian Schulze

Research output: Contribution to journalArticle

81 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)601-610
Number of pages10
JournalJournal of Heart and Lung Transplantation
Volume31
Issue number6
DOIs
StatePublished - Jun 2012
Externally publishedYes

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End Stage Liver Disease
Heart-Assist Devices
International Normalized Ratio
Liver Diseases
Heart Failure
Transplants
Survival
Equipment and Supplies
Cholestasis

Keywords

  • cardiomyopathy
  • liver dysfunction
  • risk assessment
  • transplantation
  • ventricular assist device

ASJC Scopus subject areas

  • Transplantation
  • Cardiology and Cardiovascular Medicine
  • Pulmonary and Respiratory Medicine
  • Surgery

Cite this

Liver dysfunction as a predictor of outcomes in patients with advanced heart failure requiring ventricular assist device support : Use of the Model of End-stage Liver Disease (MELD) and MELD eXcluding INR (MELD-XI) scoring system. / Yang, Jonathan A.; Kato, Tomoko S.; Shulman, Brittney P.; Takayama, Hiroo; Farr, Maryjane; Jorde, Ulrich P.; Mancini, Donna M.; Naka, Yoshifumi; Schulze, P. Christian.

In: Journal of Heart and Lung Transplantation, Vol. 31, No. 6, 06.2012, p. 601-610.

Research output: Contribution to journalArticle

Yang, Jonathan A. ; Kato, Tomoko S. ; Shulman, Brittney P. ; Takayama, Hiroo ; Farr, Maryjane ; Jorde, Ulrich P. ; Mancini, Donna M. ; Naka, Yoshifumi ; Schulze, P. Christian. / Liver dysfunction as a predictor of outcomes in patients with advanced heart failure requiring ventricular assist device support : Use of the Model of End-stage Liver Disease (MELD) and MELD eXcluding INR (MELD-XI) scoring system. In: Journal of Heart and Lung Transplantation. 2012 ; Vol. 31, No. 6. pp. 601-610.
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abstract = "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.",
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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

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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