title: Model for end-stage liver disease predicts mortality for tricuspid valve surgery.
abstract: BACKGROUND
  Patients undergoing tricuspid valve surgery have a mortality of 9.8%, which is higher than expected given the complexity of the procedure. Despite liver dysfunction seen in many patients with tricuspid disease, no existing risk model accounts for this. The Model for End-Stage Liver Disease (MELD) score accurately predicts mortality for abdominal surgery. The objective of this study was to determine if MELD could accurately predict mortality after tricuspid valve surgery and compare it to existing risk models.
  
  
  METHODS
  From 1994 to 2008, 168 patients (mean age, 61 +/- 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using chi(2), Fisher's exact test, and area under the curve (AUC) analyses.
  
  
  RESULTS
  Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96).
  
  
  CONCLUSIONS
  The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, Virginia, USA. gorav@virginia.edu
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.forename: Damien J
authors.initials: DJ
authors.lastname: Lapar
authors.forename: Brian R
authors.initials: BR
authors.lastname: Swenson
authors.forename: Suzanne A
authors.initials: SA
authors.lastname: Siefert
authors.forename: Christine
authors.initials: C
authors.lastname: Lau
authors.forename: John A
authors.initials: JA
authors.lastname: Kern
authors.forename: Benjamin B
authors.initials: BB
authors.lastname: Peeler
authors.forename: Keith E
authors.initials: KE
authors.lastname: Littlewood
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
mesh_terms: D000328:Adult; D000368:Aged; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D003404:Creatinine / Q000097:blood; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications* / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D019934:International Normalized Ratio; D008103:Liver Cirrhosis / Q000150:complications / Q000401:mortality; D017093:Liver Failure / Q000150:complications / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D051437:Renal Insufficiency / Q000150:complications / Q000401:mortality; D012189:Retrospective Studies; D014261:Tricuspid Valve / Q000601:surgery*
chemical_list: D015415:Biomarkers; D003404:Creatinine; D001663:Bilirubin