title: 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.
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.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, 622 W. 168th Street, New York, NY 10032, USA.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Yang
authors.forename: Tomoko S
authors.initials: TS
authors.lastname: Kato
authors.forename: Brittney P
authors.initials: BP
authors.lastname: Shulman
authors.forename: Hiroo
authors.initials: H
authors.lastname: Takayama
authors.forename: Maryjane
authors.initials: M
authors.lastname: Farr
authors.forename: Ulrich P
authors.initials: UP
authors.lastname: Jorde
authors.forename: Donna M
authors.initials: DM
authors.lastname: Mancini
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Naka
authors.forename: P Christian
authors.initials: PC
authors.lastname: Schulze
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D058625:End Stage Liver Disease / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology*; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000401:mortality* / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D053208:Kaplan-Meier Estimate; D008099:Liver / Q000503:physiopathology*; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D016896:Treatment Outcome