Background

Multiple organ dysfunction, including kidney and liver, is associated with impaired clinical outcome in patients with heart failure. The Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score have been reported as a predictor of adverse events in liver and heart disease. In the present study, we aimed to investigate the prognostic value of MELD-XI score in patients undergoing transcatheter mitral valve repair (TMVR).

Methods

A total of consecutive 646 patients who underwent transcatheter mitral valve repair with MitraClip for symptomatic mitral regurgitation (MR) between October 2011 and September 2018 in three high-volume German centers were retrospectively analyzed. The MELD-XI score was calculated using creatinine and total-bilirubin at baseline as follows: 5.11 × ln(Total Bilirubin) + 11.76 × ln(Creatinine) + 9.44. The cut-off was set to 12.0 as previously reported. We investigated the association between MELD-XI score and 1-year composite outcome comprising death and heart failure hospitalization after TMVR.

Results

In the total cohort of 646 patients (mean age 76.9 ± 9.3; Logistic European System for Cardiac Operative Risk Evaluation score 17.6% [interquartile range: 10.0% to 30.3%]; functional MR 64%), mean MELD-XI score was 10.7 ± 5.5, and 38% (248/646) patients had a high MELD-XI score (≧12.0). The MELD-XI score had a higher predictive value of 1-year composite outcome (AUC = 0.65, p <0.001) compared to creatinine, bilirubin, and estimated glomerular filtration rate. At 1-year follow-up, 106 patients (16%) died, and 221 patients (34%) experienced composite outcome. Kaplan-Meier curve demonstrated that a high MELD-XI score was associated with a higher incidence of 1-year adverse clinical events after TMVR (Figure). In multivariable Cox-proportional hazard models, MELD-XI score was a significant predictor of the composite outcome (Hazard ratio [HR] 1.07, 95% CI, 1.02 - 1.12, p = 0.001), death (HR 1.10, 95% CI 1.02 - 1.20, p = 0.02), and heart failure hospitalization (HR 1.06, 95% CI 1.01 - 1.12, p = 0.04) within 1 year after TMVR, after adjusting for potential confounding factors. In addition, among the patients with a high MELD-XI score, severe postprocedural tricuspid regurgitation (TR) at discharge was significantly associated with 1-year composite outcome (HR 1.75, 95% CI 1.08 – 2.74, p = 0.02). The early intervention for residual severe TR after TMVR might be a reasonable option to improve the clinical outcome.

Conclusion
The MELD-XI score was associated with impaired clinical outcome within 1 year after TMVR, and can be can be useful to predict adverse outcome after TMVR.