Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post–Liver Transplantation Mortality

Abstract

Background and Aims Enhanced sympathetic nervous activation and peripheral vasodilation in end‐stage liver disease (ESLD) may limit the importance of left ventricular ejection fraction (LVEF) as an influential prognosticator. We sought to understand the LVEF and cardiac dimensions in ESLD patients in order to define the LVEF threshold to predict all‐cause mortality after liver transplantation (LT). Approach and Results Data were collected prospectively from the Asan LT Registry between 2008 and 2016, and outcomes were retrospectively reviewed. LVEF, end‐diastolic volume index (EDVI), and end‐diastolic elastance (Eed) were measured by preoperative echocardiography. Of 2,799 patients, 452 (16.2%) had LVEF ≤ 60%, with 29 (1.0%) having LVEF < 55% and 269 (9.6%) had LVEF ≥ 70%. Over a median of 5.4‐year follow‐up, 329 (11.8%) patients died: 104 (3.7%) died within 90 days. LVEF (range, 30%‐81%) was directly proportionate to Model for End‐stage Liver Disease (MELD) scores, an index of liver disease severity, in survivors but showed a fixed flat‐line pattern in nonsurvivors (interaction P = 0.004 between groups), with lower EDVI (P = 0.013) and higher Eed (P = 0.001) in the MELD ≥ 20 group. Patients with LVEF ≤ 60% had higher 90‐day (13% vs. 7.4%; log rank, P = 0.03) and median 5.4‐year (26.7% vs. 16.2%; log rank, P = 0.003) mortality rates in the MELD ≥ 20 group, respectively, compared to those with LVEF > 60%. Specifically, in the MELD > 35 group, median 5.4‐year mortality rate was 53.3% in patients with LVEF ≤ 60% versus 24% in those with LVEF > 60% (log rank P < 0.001). By contrast, mortality rates of LVEF ≤ 60% and > 60% were similar in the MELD < 20 group (log rank P = 0.817). Conclusions LVEF ≤ 60% is strongly associated with higher post‐LT mortality rates in the MELD ≥ 20 group, indicating the need to appraise both LVEF and liver disease severity simultaneously. Enhanced diastolic elastance with low EDVI provides insights into pathogenesis of low LVEF in nonsurvivors with MELD ≥ 20.

Markedly prolonged QTc interval in end‐stage liver disease and risk of 30‐day cardiovascular event after liver transplant

“…For multivariable analysis, backward elimination with variables yielding P values < 0.1 in the univariate analysis was performed. To further reduce potential bias caused by omitted confounders in the multivariate model and to ensure robustness, an inverse probability of treatment weighting (IPTW) analysis was applied, in which propensity scores were generated by a full non‐parsimonious model that included all covariates in Table 1 17,18 . Patients with QTc > 500 ms were weighted by the inverse of the propensity score, and those with QTc ≤ 500 ms were weighted by the inverse of 1 − propensity score.…”

Cirrhotic Cardiomyopathy in the Era of Liver Transplantation: Time for Precise Stepwise Evaluation

“…However, choosing a higher cut-off value (55-60%) might be necessary for LC patients, due to their decreased afterload and increased preload, which could explain the normal LVEF values found in the majority of the studies [16][17][18][19][20][21][22][23][24][25][26]28]. Noteworthy, LVEF ≤ 60% was recently reported in a very large group of LC patients strongly associated with higher post-LT mortality rates in the MELD ≥20 subgroup, suggesting that systolic dysfunction and severity of liver disease must be evaluated simultaneously in the pre-LT assessment protocol [28]. In conclusion, we recommend that the threshold for the diagnosis of LV systolic dysfunction in LC patients should be maintained at a higher cut-off (LVEF<55%), different from that of the 2019 consensus definition (LVEF<50%).…”

Letter to the Editor: Appraisal of Cardiac Ejection Fraction With Liver Disease Severity

“…With interest, we read the study by Kwon et al, (1) which analyzed a large cohort of liver transplantation recipients. They suggested preoperative left ventricular ejection fraction (LVEF) <60% as a cutoff in patients with Model for End-Stage Liver Disease (MELD) score ≥ 20 to predict posttransplant all-cause mortality or graft failure.…”