Trapianto di cuore ed insufficienza epato-renale: impatto del MELD-XI (Model of End-Stage Liver Disease EXcluding INR) score sugli outcomes postoperatori

Introduction: Preoperative liver and renal dysfunction remain surgical risk factors for both postoperative morbidity and mortality. The ‘Model of End-Stage Liver Disease Excluding INR’ score (MELD-XI) calculation may help as predictor in patients with advanced heart failure. We analyzed the impact of progressive elevated MELD-XI values among heart transplant recipients at our institution. Methods: The data of a total of 425 consecutive adult patients who underwent heart transplantation, between January 2000 and August 2018, have been reviewed and divided into three cohorts according to preoperative MELD-XI calculations (MELD-XI <11; MELD-XI 11-18; MELD-XI >18). Early and late outcomes have been analyzed. Results: Patients with MELD-XI score >18 had a more critical clinical condition preoperatively and resulted to have a higher risk of early mortality (HR 1.45 [1.11-1.67], p <0.001). They showed high risk for postoperative dialysis (HR 2.8 [1.5-5.3], p <0.001), rethoracothomy for bleeding (HR 2.1 [1.2-4.1], p =0.001), prolonged time of mechanical ventilation, time of intensive care unit stay (HR 2.2 [1.3-3.8], p =0.005), and graft failure requiring mechanical circulatory support (HR 1.9 [1.1-3.3], p =0.003). After risk adjustment per MELD-XI cohort, ischemic dilated cardiomyopathy, redo operation and cold ischemic time >240 minutes resulted the strongest predictors of early mortality (p0.001). The 5-y and 10-y survival for MELD-XI >18 cohort was 63% and 47% versus 72% and 59% in the control group (MELD-XI <18) (log-rank, p <0.001). Conclusions: Patients with elevated preoperative MELD-XI profile presented more comorbidities and significantly lower survival. This suggests the MELD-XI score may contribute to provide further insight into appropriate recipient and eventual donor selection. Renal insufficiency and congestive hepatopathy should be properly optimized before heart transplantion.