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 χ2, 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.

Long-Term Outcome of Cardiac Surgery in 1,040 Liver Cirrhosis Patient ― Nationwide Population-Based Cohort Study ―

“…31 Furthermore, patients with liver dysfunction, in particular, have associated tricuspid valve disease due to hepatic congestion. 32 Consistent with this, most of the present LC patients (61.2%) received valve and combined CABG and valve surgeries. To date, a large population study of cirrhotic patients undergoing valve surgery is still lacking.…”

Prognostic Value of Hepatorenal Function By Modified Model for End‐stage Liver Disease (MELD) Score in Patients Undergoing Tricuspid Annuloplasty

“…In patients with valvular heart disease, the prevalence of atrial fibrillation is high and thus a large proportion of patients are prescribed anticoagulation. A study by Ailawadi et al31 demonstrated that the MELD score was predictive of adverse outcome in patients undergoing tricuspid surgery, although 44% were prescribed warfarin preoperatively. Nonetheless, the accuracy of the MELD score that includes INR assessment in evaluating hepatopathy in patients who require anticoagulation is arguable.…”

Transplantation and Mechanical Circulatory Support in Congenital Heart Disease

“…The Model for End-Stage Liver Disease (MELD) score has been shown to stratify patients undergoing coronary artery bypass and tricuspid valve surgery (MELD >15) according to risk, 131 with higher scores predicting increased mortality. MELD scores have also been shown to predict mortality in HF patients being evaluated for transplantation, 132 undergoing transplantation (MELD and modMELD, which substitutes albumin for international normalized ratio), 133 or left VAD (MELD ≥17).…”