Author + information
- Tomoko S. Kato, MD, PhD and
- P. Christian Schulze, MD, PhD∗ ()
- ↵∗Department of Medicine, Division of Cardiology, Columbia University Medical Center, Center for Advanced Cardiac Care, 622 West 168th Street, PH 10, Room 203, New York, New York 10032
We thank Dr. Valentova and colleagues for their insightful comments on our recent study (1) of liver function abnormalities characterized by various MELD (Model of End Stage Liver Disease) scoring systems in patients evaluated for heart transplantation (HTx). On the basis of our analysis, utilization of MELD scoring systems may improve our risk prediction on the basis of a composite evaluation of end-organ dysfunction including liver and renal functional abnormalities. Of note, the use of the standard MELD score is limited to patients not on oral anticoagulation due to the impact of vitamin K antagonists on the international normalized ratio (INR), which is an essential component of the standard MELD score. For that reason, we analyzed both patients on and off oral anticoagulants separately and included the modified MELD-XI score, which allows characterization of patients on vitamin K antagonists.
Dr. Valentova and colleagues also state that in patients with liver cirrhosis, the use of total bilirubin is most appropriate and that liver cirrhosis is a rare finding in patients with HF. This does not reflect our experience, as the degree of liver cirrhosis is a frequent concern in our population of patients evaluated for HTx; in particular, in patients with longstanding right and biventricular heart failure, patients on left ventricular assist device support and patients with congenital heart disease after, for example, Fontan repair. At our center, we performed liver biopsies in more than 5% of all transplant candidates evaluated between January 1, 2000 and April 1, 2013 due to the suspicion of structural liver damage such as liver fibrosis secondary to congestive hepatopathy, previous hepatitis or irreversible liver function abnormalities, and concomitant imaging abnormalities. Unfortunately, our current analysis focused on the utilization of MELD scores that included only total bilirubin, and we did not include direct bilirubin into our analysis (1). It would be interesting, however, to study this parameter in a subsequent analysis. Nevertheless, the impact of bilirubin and its specific statistical weight within the composite MELD scores has only been established for total bilirubin, and it will require adjustments if direct bilirubin will be used instead of total bilirubin.
We agree with Dr. Valentova and colleagues that elevated MELD scores might reflect more severe comorbidities and more advanced HF. However, in our cohort, we did not detect differences in the prevalence of diabetes mellitus or atrial fibrillation. Of note, peak volume of oxygen use was lower (13.4 ± 5.1 ml/min/kg vs. 11.5 ± 3.7 ml/min/kg; p = 0.0005) whereas the Seattle Heart Failure Model score was higher in patients with higher MELD scores (0.38 ± 0.8 vs. 0.64 ± 0.8; p = 0.0087). Therefore, it will require further prospective studies to characterize the specific impact of the MELD scoring system for the prognostic evaluation both before and after HTx. However, we have shown in previous analyses that both mechanical unloading with left ventricular assist devices (2) and HTx (3) lead to a decrease in MELD scores. Most importantly, while the role and impact of pharmacologic strategies is unclear, we have shown that patients who normalize MELD and MELD-XI (MELD Excluding INR) scores after left ventricular assist device implantation have a better prognosis following HTx than do patients with persistently elevated MELD scores (2). Therefore, we suggest that the MELD scoring system is a novel risk assessment tool for the characterization of patients with advanced HF.
- American College of Cardiology Foundation
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