Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy

Multi-organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD-XI score and the long-term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated.

Clinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD-XI score: first tertile (MELD-XI = 9.44, n = 95), second tertile (9.44 < MELD-XI < 13.4, n = 94), and third tertile (MELD-XI ≥ 13.4, n = 94). The primary endpoint was all-cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N-terminal pro-brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow-up of 30 months (inter-quartile range, 9-67), 105 patients (37.1%) died. Kaplan-Meier analysis revealed that patients with a higher MELD-XI score had a greater risk of all-cause mortality (log-rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD-XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00-1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01-1.09, P = 0.005, respectively). A higher MELD-XI score was associated with a greater risk of all-cause mortality than a lower MELD-XI score regardless of whether a pacemaker or defibrillator was implanted (log-rank test: P = 0.010 and P < 0.001, respectively).

Impaired hepatorenal function assessed by the MELD-XI score was associated with older age, higher prevalence of multiple co-morbidities, severity of HF, lower CRT response rates, and subsequent all-cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD-XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.