Impact of preoperative liver dysfunction on outcomes in patients with left ventricular assist devices

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review

Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.

Impact of Preoperative Liver Function on Short-Term HeartMate 3 Outcomes

Although left ventricular assist device (LVAD) therapy is associated with improved survival, the impact of preoperative liver function on short-term outcomes is unclear. We conducted a retrospective review of all primary HeartMate 3 LVAD implants at a single center. Composite metrics of hepatic function including the model for end-stage liver disease (MELD), the MELD with sodium, and the MELD excluding international normalized ratio (MELD-XI) were evaluated. Receiver operator characteristic curves were compared to determine which equation was most predictive of 1-year survival. Primary stratification was based on MELD-XI tertiles. Secondary stratification was based on hypoalbuminemia (<3.0 mg/100 ml). A total of 94 patients underwent primary LVAD implantation from 2017 to 2022. MELD-XI and hypoalbuminemia were most associated with 1-year outcomes. When stratified by MELD tertiles, higher MELD was strongly associated with decreased 30 days (100.00% vs 100.00% vs 90.32%, p = 0.04), 1-year (93.00% vs 93.32% vs 69.79%, p = 0.01), and 2-year survival (93.00% vs 83.21% vs 69.79%, p = 0.04). In addition, while hypoalbuminemia was associated with similar 30 days (97.87% vs 95.74%, p = 0.56) survival, it was associated with a significant decrease in 1-year (92.93% vs 77.92%, p = 0.03) and 2-year survival (92.93% vs 68.89%, p <0.01). These results persisted on multivariable analysis for both MELD-XI score (p = 0.04) and hypoalbuminemia (p = 0.04). In conclusion, this is the first study to demonstrate that preoperative MELD-XI score and serum albumin levels are associated with short-term HeartMate 3 outcomes.

Stratification of Destination Therapy Candidates by J-HeartMate Risk Score Among Elderly Non-Responders to Cardiac Resynchronization Therapy

Background: For elderly patients with refractory heart failure (HF), destination therapy (DT) with a continuous-flow left ventricular assist device (LVAD) is a possible treatment. The aim of DT is for long-term, satisfying quality of life on LVAD support. Previously, elderly non-responders to cardiac resynchronization therapy (CRT) were primarily destined for palliative care, but DT has been available in Japan since April 30, 2021. This study investigated the prognosis of elderly CRT non-responders and assessed the feasibility of DT in these patients based on the J-HeartMate Risk Score (J-HMRS).

Methods and Results: Of the 559 patients who underwent CRT at Tokyo Women’s Medical University between 2000 and 2018, 198 were aged 65–75 years. Among these, 76 were identified as non-responders based on echocardiographic data, and were included in this study. We calculated patients’ J-HMRS and investigated associations between the J-HMRS and cardiac events after CRT. Patients were divided into 3 groups according to the J-HMRS: low (n=23), medium (n=29), and high (n=24) risk. Patients in the low-risk group experienced as many HF rehospitalizations and ventricular arrhythmia events as those in the other groups. However, survival analysis revealed that, after CRT, survival was higher for patients in the low- compared with high-risk group (P=0.04).

Conclusions: The J-HMRS classified 30% of elderly CRT non-responders as low risk and as suitable candidates for DT in Japan.

Oxidative Stress Markers and Modified Model for End-Stage Liver Disease Are Associated with Outcomes in Patients with Advanced Heart Failure Receiving Bridged Therapy with Continuous-Flow Left Ventricular Assist Devices

Left ventricular assist device (LVAD) is well established as an alternative treatment for end-stage heart failure (HF) patients. The aim of the study was to determine the prognostic value of oxidative stress markers and the modified Model for End-Stage Liver Disease (modMELD) in patients receiving bridged therapy with continuous-flow LVAD. We prospectively analyzed 36 end-stage HF patients who received LVAD therapy between 2015 and 2018. The total antioxidant capacity (TAC) and total oxidant status (TOS) were measured by the methods described by Erel. The oxidative stress index (OSI) was defined as the ratio of the TOS to TAC levels. The modMELD scores were calculated based on the serum bilirubin, creatinine, and albumin levels. The patients’ median age was 58 (50–63.0) years. During the 1.5-years follow-up, a major adverse cardiac event—MACE (death, stroke, or pump thrombosis) was observed in 17 patients (47.2%). The area under the receiver operating characteristics curves (AUCs) indicated a good prognostic power of TAC (AUC 0.7183 (0.5417–0.8948)), TOS (AUC 0.9149 (0.8205–0.9298)), OSI (AUC 0.9628 (0.9030–0.9821)), and modMELD (AUC 0.87 (0.7494–0.9905)) to predict a MACE. Oxidative stress markers serum concentrations, as well as the modMELD score, allow the identification of patients with a risk of MACE.

Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients

OBJECTIVES

Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant.

MATERIALS AND METHODS

Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease.

RESULTS

Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01).

CONCLUSIONS

Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.

Cardiac Surgery 2020 Reviewed

In 2020, nearly 30,000 published references appeared in the PubMed for the search term "cardiac surgery." While SARS-CoV-2 affected the number of surgical procedures, it did not affect outcomes reporting. Using the PRISMA approach, we selected relevant publications and prepared a results-oriented summary. We reviewed primarily the fields of coronary and conventional valve surgery and their overlap with interventional alternatives. The coronary field started with a discussion on trial data value and their interpretation. Registry comparisons of coronary artery bypass surgery (CABG) and percutaneous coronary intervention confirmed outcomes for severe coronary artery disease and advanced comorbidities with CABG. Multiple arterial grafting was best. In aortic valve surgery, meta-analyses of randomized trials report that transcatheter aortic valve implantation may provide a short-term advantage but long-term survival may be better with classic aortic valve replacement (AVR). Minimally invasive AVR and decellularized homografts emerged as hopeful techniques. In mitral and tricuspid valve surgery, excellent perioperative and long-term outcomes were presented for structural mitral regurgitation. For both, coronary and valve surgery, outcomes are strongly dependent on surgeon expertise. Kidney disease increases perioperative risk, but does not limit the surgical treatment effect. Finally, a cursory look is thrown on aortic, transplant, and assist-device surgery with a glimpse into the current stand of xenotransplantation. As in recent years, this article summarizes publications perceived as important by us. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide up-to-date information for decision-making and patient information.

Assessing in-hospital cardiovascular, thrombotic and bleeding outcomes in patients with chronic liver disease undergoing left ventricular assist device implantation

INTRODUCTION

Chronic liver disease (CLD) and advanced heart failure (HF) often co-exist with coagulopathy and hematologic abnormalities being major concerns in this cohort. Perioperative outcomes of patients undergoing LVAD implantation can be affected by coagulopathy, associated with a higher International Normalized Ratio (INR) and cytopenias, as well as pre-operative use of antiplatelet therapy and systemic anticoagulation. Our study is aimed at evaluating the in-hospital mortality and clinical outcomes of patients with CLD who underwent LVAD implantation compared to patients who underwent LVAD implantation without CLD.

METHODS

The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with chronic liver disease and those without, who underwent LVAD implantation.

RESULTS

A total of 22,955 patients underwent LVAD implantation, 2200 of which had CLD. There was no difference in mean age between those with and without CLD (52.8 ± 14.2 vs. 55.7 ± 15.4 years old, p < 0.001), and 23.7% of patients were female. The proportion of patients with CLD undergoing LVAD implantation trended downward between 2012 and 2017 (average annual growth rate: "-14.8%"). In-hospital post-LVAD outcomes revealed: all-cause inpatient mortality (14.8% vs. 11.1%), major bleeding (34.3% vs. 30.2%), transfusion of platelets (18.0% vs. 14.0%), subarachnoid hemorrhage (1.6% vs. 0.7%) and hospital length of stay were greater in patients with CLD (p < 0.001 for all values). LVAD thrombosis (6.6% vs. 9.4%) and postoperative ischemic stroke (3.4% vs. 6.1%) occurred less in patients with CLD (p < 0.001 for both). There were no statistically significant differences in occurrence of post-LVAD gastrointestinal bleeding and transfusion of fresh frozen plasma or packed red blood cells (p > 0.05 for all). Using a multivariate logistic regression model to adjust for confounding factors, CLD was predictive of increased in-hospital all-cause mortality in patients undergoing LVAD implantation (adjusted odds ratio: 1.29, 95% confidence interval [CI]; 1.06 to 1.56, p = 0.010).

CONCLUSION

LVAD implantation in patients with chronic liver disease was associated with increased mortality and post-LVAD major bleeding with increased utilization of platelet products yet comparable thrombotic complications. Further studies are needed to evaluate the balance and pathophysiology of bleeding risks when compared to thrombosis, as well as predictors in patients with chronic liver disease.

Prognostic value of the modified model for end-stage liver disease (MELD) score including albumin in acute heart failure

Background

Liver and renal function evaluated by the model for end-stage liver disease (MELD) score, the MELD excluding the international normalized ratio (MELD_XI) score and the MELD including sodium (MELD_sodium) score have been considered predictors of adverse events for patients with acute heart failure (AHF). However, the prognostic value of the MELD including albumin (MELD_albumin) score in patients with AHF has not been assessed.

Methods

A total of 466 patients with AHF were prospectively evaluated. We compared the accuracy of the 4 MELD score formulas using the time-dependent receiver operating characteristic (ROC) curve and corresponding areas under the curve (AUC).

Results

During a median follow-up period of 34 months, 196 deaths occurred. In the fully adjusted Cox regression model, standardized hazard ratios with 95% confidence interval expressing the risk of all-cause mortality were 1.22 (1.06–1.40), 1.20 (1.04–1.39), 1.23 (1.06–1.42) and 1.21 (1.05–1.41) for MELD, MELD_XI, MELD_sodium and MELD_albumin scores, respectively. The MELD_albumin score showed the best prognostic accuracy (AUC = 0.658) for the prediction of long-term all-cause mortality, followed by the MELD_sodium score (AUC = 0.590), the MELD score (AUC = 0.580), and the MELD_XI score (AUC = 0.544); the MELD_albumin score performs significantly more accurate than MELD and MELD_XI score for predicting the risk of all-cause mortality. Considering reclassification, MELD_albumin score increased the net reclassification improvement over and beyond MELD (13.1%, P = 0.003), MELD_XI (14.8%, P = 0.002), and MELD_sodium (11.9%, P = 0.006) scores for all-cause mortality.

Conclusions

The MELD_albumin score increases risk stratification of all-cause mortality over and beyond the MELD score and the other modified MELD scores in patients with acute heart failure.