Long-Term Follow-Up in Liver Transplantation and Combined Cardiac Surgery: Validation and Refinement of the LT+CS
Laura B Oliveira1, Chase J Wehrle1, Sarah Wehbe1
1From the Digestive Disease Institute (Oliveira, Wehrle, Wehbe, Singer, Hashimoto, Diago-Uso, Schlegel, Esfeh), Cleveland Clinic, Cleveland, OH.
Insights
Combined liver and cardiac surgery offers survival benefits for patients with end-stage liver disease and cardiac dysfunction. Refined risk scores improve patient selection and outcomes in this complex procedure.
Area of Science:
- Cardiology
- Hepatology
- Transplantation Surgery
Background:
- Combined liver transplantation and cardiac surgery (LT+CS) is a critical option for patients with end-stage liver disease (ESLD) and severe cardiac dysfunction.
- Limited evidence exists on long-term outcomes and prognostic factors for this complex procedure.
Purpose of the Study:
- To evaluate long-term survival and identify prognostic factors in patients undergoing combined LT+CS.
- To validate and refine the LT-CS risk score using machine learning techniques.
Main Methods:
- Analysis of 46 patients who underwent single-staged LT+CS between 2005-2023 with at least 1-year follow-up.
- Utilized univariate and multivariate Cox proportional hazards models to identify predictors of survival.
- Employed Leave-One-Out Cross-Validation (LOOCV) for risk score refinement and validation.
Main Results:
- One- and five-year survival rates were 74.2% and 50%, respectively.
- Chronic kidney disease (CKD) was a significant negative predictor of 5-year survival (HR=12.28).
- The refined LT-CS-2.0 score demonstrated good predictive accuracy (AUC=0.683 for 5-year OS) and risk stratification capabilities.
Conclusions:
- Combined LT and CS can achieve acceptable survival rates in carefully selected patients.
- The LT-CS-1.0 risk score has improved survival rates, and the LT-CS-2.0 score offers further potential for risk stratification.
- This approach should be considered in specialized centers for appropriate patient candidates.
Background:
Combined liver transplantation (LT) and cardiac surgery (LT+CS) is a therapeutic option for patients with end-stage liver disease (ESLD) and severe cardiac dysfunction. Despite its potential, evidence on long-term outcomes and prognostic factors remains limited.
Study Design:
Forty-six patients underwent single-staged LT+CS (2005 to 2023) and had a minimum 1-year follow-up. Univariate and multivariate Cox proportional hazards models assessed independent predictors of long-term survival (1 and 5 years), and a machine learning-based leave-one-out cross-validation (LOOCV) technique was used to validate and refine the LT-CS-2.0 risk score.
Results:
Actuarial 1- and 5-year survival rates were 74.2% and 50%, respectively. Negative predictors of 5-year overall survival (OS) were GFR (odds ratio [OR] 1.02, p = 0.031), chronic kidney disease (CKD) (OR 0.13, p = 0.026), and valve surgery (OR 6.67, p = 0.045). The largest effect in multivariate analysis was chronic kidney disease (hazard ratio 12.28, 95% CI 1.01 to 152.43). Since implementation of the LT+CS-1.0 score in 2022, there has been an improvement in patient survival (log-rank p < 0.001). Leave-one-out cross-validation analysis identified the most influential variables for the LT-CS-2.0 risk score: Metabolic-associated steatohepatitis had a relative weighted impact of 2.66 vs all-cause renal dysfunction (2.63) and aortic stenosis (2.20). The modified LT-CS-2.0 risk score was associated with an increased mortality with an area under the curve 0.683 (p = 0.03) for 5-year OS and area under the curve 0.863 (p < 0.0001) specifically in valve surgery patients. Kaplan-Meier analysis showed 1-, 3-, and 5-year survival of 95.7%, 95.7%, and 87.7% (low-risk) vs 61.9%, 61.9%, and 49.5% (high-risk), with a log-rank p = 0.001.
Conclusions:
Combined LT and CS provides acceptable survival in this challenging population. Centers should pursue this approach in selected patients. The LT-CS-1.0 score risk has helped our center improve survival, and the refined LT-CS-2.0 score may further help risk stratify patients.
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