Abnormal left ventricular mass as a prognostic marker for outcomes in infants and children with cirrhosis

Cirrhotic cardiomyopathy (CCM), a clinically consequential comorbidity of cirrhosis, remains undefined and underappreciated in children. This study aimed to characterize myocardial structural, functional, morphometric, and histopathologic features in pediatric cirrhosis and objectively derive a reliable echocardiographic (2DE) metric to predict perioperative adverse events, including mortality.

2DE, morphometry, histopathology, and vasoactive-inotropic score (VIS) were compared between children with (n=226) and without (n=160) cirrhosis listed for liver transplantation (LT) over 2011-2021. Discriminatory performance of left ventricular mass index (height)^2.7(LVMI g/m^2.7) for predicting waitlist decompensation, composite serious adverse events post liver transplant and mortality was assessed using ROC analysis, with AUCs and optimal thresholds compared against PELD-Cr/MELD scores.

LV mass was significantly higher in children with cirrhosis on 2DE and necropsy specimens compared to non-cirrhotic controls, with ∼25% demonstrating LV hypertrophy, with OR of 6.9 [CI 3,16], p< 0.0001. In the cirrhotic cohort, LVMI correlated with vasoactive needs under stress of LT (p <0.001) and was significantly higher in patients with WLD, CSAE, and non-survivors. In cirrhosis, LVMI values ≥ 88 g/m^2.7, ≥ 91 g/m^2.7, and ≥ 95 g/m^2.7 were independently associated with WLD, CSAE, and mortality, when adjusting for PELD-Cr/MELD, bilirubin, and INR (p <0.01). Combining LVMI + PELD-Cr/MELD significantly outperformed PELD-Cr/MELD in discriminating both WLD and CSAE, whereas LVMI alone significantly outperformed PELD-Cr/MELD for CSAE and was comparable for WLD. All three models performed comparably in discriminating death.

LVMI is a strong predictor of morbidity and mortality, serving as a prognostic marker in children with cirrhosis. Incorporating LVMI into PELD-Cr/MELD may enhance risk stratification and organ allocation.