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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 110-118

Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score independently predicts in-hospital cardiac and 1-year all-cause mortality in noncardiac surgery


Department of Cardiology, Faculty of Medicine, Başkent University, Ankara, Turkey

Date of Submission31-Jan-2020
Date of Decision30-Mar-2020
Date of Acceptance17-Apr-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Orcun Ciftci
Department of Cardiology, Faculty of Medicine, Baskent University, Yukari Bahçelievler, Mehallesi Maresal Fevzi Çakmak Caddesi No: 45, Çankaya, Ankara 06490
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCA.IJCA_4_20

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  Abstract 


Objective: Cardiac adverse events are one of the most-feared complications among patients undergoing noncardiac surgery. Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score has been shown to carry prognostic implications for patients with various cardiac conditions, but it has not been used for patients undergoing noncardiac surgery. We aimed to determine the role of MELD-XI score for the prediction of mortality in high-risk noncardiac surgical candidates. Materials and Methods: Eighty-four patients with high-risk cardiac conditions undergoing elective or urgent noncardiac surgery were reviewed for in-hospital cardiac and 1-year all-cause mortality. MELD-XI score was compared between the surviving and deceased patients. It was correlated with both mortality rates; its predictive power for mortality prediction was tested. Results: The median age was 81 (interquartile range 18) years, and 41 (48.8%) patients were male. All patients had at least one high-risk cardiac condition. Forty patients experienced a cardiac adverse event. Sixteen (19%) patients died at hospital and 40 (47.6%) patients died by 1 year, and both groups had significantly higher MELD-XI scores than survivors (12.23 [6.53] vs. 9.66 [3.81]; P = 0.001 and 10.80 [6.31] vs. 9.70 [3.70]; P = 0.037, respectively). MELD-XI score independently predicted in-hospital cardiac mortality (OR: 1.254 [95% confidence interval [CI]: 1.028–1.530]; P < 0.05) and 1-year all-cause mortality (OR: 1.258 [95% CI: 1.057–1.498; P < 0.01). MELD-XI predicted in-hospital cardiac mortality with a fair sensitivity and a moderate specificity and 1-year all-cause mortality with a fair sensitivity but poor specificity. A MELD-XI score >8.87 was associated with a significantly worse 1-year survival (log rank test, P < 0.05). Conclusion: MELD-XI score is independently associated with in-hospital cardiac and 1-year all-cause mortality among high-risk patients undergoing noncardiac surgery.

Keywords: Cardiac, high-risk, Model for end-stage liver disease excluding international normalized ratio score, mortality, noncardiac surgery


How to cite this article:
Ciftci O, Keskin S, Okyay K, Muderrisoglu IH. Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score independently predicts in-hospital cardiac and 1-year all-cause mortality in noncardiac surgery. Int J Cardiovasc Acad 2020;6:110-8

How to cite this URL:
Ciftci O, Keskin S, Okyay K, Muderrisoglu IH. Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score independently predicts in-hospital cardiac and 1-year all-cause mortality in noncardiac surgery. Int J Cardiovasc Acad [serial online] 2020 [cited 2020 Oct 24];6:110-8. Available from: https://www.ijcva.com/text.asp?2020/6/3/110/296238




  Introduction Top


Cardiac adverse events including death are one of the most feared complications of noncardiac surgery, for which several high-risk cardiac conditions have been defined and a number of risk scores have been developed.[1],[2],[3] Model for end-stage liver disease (MELD) score was developed to predict clinical outcomes primarily in patients with liver disease,[4],[5] but it has also been used in patients with multiorgan failure,[6] heart failure,[7] or left ventricular assist devices (LVADs).[8],[9],[10] MELD-XI score is a derivative of MELD score, calculated by excluding international normalized ratio (INR) from the parameters for patients who use anticoagulants. MELD-XI score has also been shown to predict mortality in various cardiac conditions.[11],[12],[13],[14],[15],[16] Herein, we aimed to study MELD-XI score to predict mortality among high-risk patients undergoing elective or urgent noncardiac surgery.


  Materials and Methods Top


This study was approved by the Local Ethics Committee (Approval Date 25.04.2019, Approval No.: KA 19/156) and supported by the Local University Research Fund. The demographic, clinical, electrocardiographic, echocardiographic, and biochemical data of 84 patients who underwent elective or urgent noncardiac surgery under general anesthesia between January 1, 2013, and January 1, 2018, were retrospectively reviewed from written medical records and hospital data automation system.

The type of elective or urgent noncardiac surgery and risk status of the individual patients were recorded, and only high-risk noncardiac surgical candidates were enrolled.[1] The elective noncardiac surgical operations included in the present the study were the ones that could not be delayed due to the severity of the underlying condition, where the risk of postponing surgery would outweigh surgical risk. The risk of noncardiac surgery was determined by the consulting cardiologist. The high-risk cardiac conditions included all vascular diseases undergoing surgery; severe aortic stenosis, as defined as a mean transaortic gradient ≥40 mmHg and/or a valve area <1.0 cm 2 on transthoracic echocardiography; severe mitral stenosis, as defined as a mean transmitral gradient of ≥10 mmHg and/or a mitral valve area <1 cm 2 on transthoracic echocardiography; severe pulmonary arterial hypertension defined as a mean pulmonary artery pressure of ≥70 mmHg on transthoracic echocardiography and/or a mean pulmonary artery pressure of ≥40 on a recent cardiac catheterization; multiple prosthetic heart valves; serious ventricular arrhythmias including ventricular tachycardia, ventricular flutter, or ventricular fibrillation, or frequent ventricular premature depolarizations with reduced left ventricular systolic function; atrial fibrillation or flutter with rapid ventricular rate response (>110/min at rest); recent or current acute coronary syndromes or myocardial infarction; severe decompensated or low-output heart failure; and uncontrollable angina pectoris despite maximal medical therapy or previous coronary intervention. None of the patients underwent surgical or percutaneous correction of high-risk cardiac conditions due to either urgency of noncardiac surgery or presence of multiple comorbidity risking procedural safety, such as hematological disorders (coagulopathies, bleeding diatheses, and anticoagulant use), acute renal failure, acute hepatic failure, contrast agent allergy, active infection, hypoxemia or decompensated heart failure, or overall poor patient status. All patients received appropriate therapy against individual high-risk cardiac conditions, including anti-ischemic therapy composed of oxygen, beta-blockers, nitrates, acetylsalicylic acid, and statins; appropriate antihypertensive therapy using intravenous or oral antihypertensives for uncontrolled or severe hypertension; heart rate control using digoxin, beta-blockers or non-dihydropyridine calcium channel blockers, and anticoagulation with low-molecular-weight heparin for atrial fibrillation or atrial flutter; prompt defibrillation or cardioversion plus amiodarone and electrolyte replacement for serious ventricular arrhythmias; loop diuretics, aldosterone antagonists, oxygen, nitrates, beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for decompensated heart failure; and diuretics, beta-blockers, and/or calcium channel blockers for severe mitral stenosis.

Preoperative revised cardiac risk index (Lee score), which was developed for perioperative cardiac adverse events in 1999,[3] was calculated for all patients using six risk factors including high-risk type of surgery (intraperitoneal, intrathoracic, or suprainguinal vascular), history of coronary artery disease (IHD), history of congestive heart failure, history of cerebrovascular disease, preoperative insulin treatment, and preoperative serum creatinine >2.0 mg/dL. MELD-XI score was calculated using the logarithmic conversions of serum creatinine and total serum bilirubin in the following manner: 5.11× ln (serum bilirubin in mg/dL) + 11.76 × ln (serum creatinine in mg/dL) +9.44. Serum creatinine and total bilirubin values below 1.0 mg/dL were rounded up to 1 mg/dL. Serum creatinine values of patients receiving hemodialysis were set to 4 mg/dL.

All in-hospital perioperative cardiac adverse events and deaths were recorded. Cardiac adverse events were defined as perioperative ischemia and/or infarction, pulmonary thromboembolism, ventricular tachycardia, fibrillation, asystole, high-grade atrioventricular block, supraventricular tachycardia with rapid ventricular response, and decompensated and/or low-output heart failure. Cardiac death was defined as that occurring due to the following: myocardial infarction and/or ischemia as evidenced by typical ischemic ECG changes and/or typical rise and fall of cardiac biomarkers of injury; serious ventricular tachyarrhythmias, serious bradyarrhythmias and asystole, supraventricular arrhythmias with rapid ventricular rate response, pericardial tamponade, acute aortic dissection, coronary dissection or embolism, and pulmonary thromboembolism. Information about postdischarge 1-year all-cause mortality was obtained from the records of the local births, deaths, and marriages registration office.

The exclusion criteria were as follows: undergoing cardiac or low-to-intermediate risk surgery; surgical or transcatheter correction of cardiac high-risk condition before noncardiac surgery, thus reducing perioperative risk; postdischarge deaths due to suicide, homicide, accidents, or intoxications; and unknown postdischarge survival status.

No patient consent was obtained from any patient due to the retrospective nature of the study.

Statistical analysis

The study data were analyzed using SPSS (Statistical Package for the Social Sciences) Windows 21.0 (IBM Inc, USA) software. The distribution of continuous variables was tested using the Kolmogorov–Smirnov test. The normally distributed continuous variables were expressed as mean ± standard deviation; the nonnormally distributed ones as median and interquartile range (IQR); and categorical variables as number and percentage. Normally distributed continuous variables were compared with the independent samples t-test; nonnormally distributed continuous variables with the Mann–Whitney-U-test; and the categorical variables with the Chi-square test.

The significant predictors of both in-hospital total and 1-year mortality were initially tested with a univariate analysis using all available demographic, clinical, biochemical, and echocardiographic variables. All univariate predictors of mortality with P < 0.25 were then used in a binary logistic regression model with backward LR method to determine the independent predictors of both mortality rates. Receiver operating characteristic (ROC) curve was drawn to determine a significant cutoff point of MELD-XI score for in-hospital cardiac and 1-year all-cause mortality. Log-rank test and Kaplan–Meier survival analysis were performed to assess the effect of MELD-XI score on 1-year all-cause survival. P < 0.05 was considered statistically significant for all tests.


  Results Top


The overall characteristics of the study population are shown in [Table 1]. All patients underwent elective or urgent noncardiac surgery under general anesthesia, and the majority (71.4%) of patients underwent general surgery or orthopedic operations. A total of 60 (71.4%) operations were urgent; 24 (28.6%) operations were elective. The most common cardiac high-risk conditions were decompensated heart failure, atrial fibrillation/flutter with rapid ventricular response (each 21.8%), severe valvular stenosis (17.2%), and pulmonary hypertension (16.1%). Forty (47.6%) patients experienced perioperative adverse cardiac events [Table 2]. A total of 16 (19.0%) patients died during perioperative period and 24 (28.6%) patients died by 1 year after hospital discharge, so that a total of 40 (47.6%) patients died by 1 year. The documented cardiac adverse events and etiologies of in-hospital cardiac death are shown in [Table 2]. Those who died at hospital had a significantly higher serum creatinine level (P < 0.01), hemoglobin level (P < 0.05), and rate of angina pectoris (P < 0.05), but a lower rate of perioperative beta-blocker use (P < 0.05) compared to the survivors. Patients who died by the end of 1 year had a significantly lower hemoglobin level, a significantly higher serum AST level, and a significantly higher rate of pulmonary hypertension (P < 0.05 for all comparisons) than the survivors. Other clinical, demographic, and laboratory data were similar between the deceased and surviving patients [Table 3] and [Table 4].
Table 1: Overall characteristics of the study population (n=84)

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Table 2: Number of in-hospital cardiac adverse events and deaths by underlying disorder

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Table 3: Comparison of demographic, clinical, and cardiac and biochemical variables between the study groups with and without in-hospital cardiac mortality

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Table 4: Comparison of demographic, clinical, biochemical, and cardiac testing variables and model for end-stage liver disease -XI score in patients with and without 1-year mortality

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The comparison of revised cardiac risk index (Lee) score between the deceased and survivor groups revealed that it was significantly higher in the patients with in-hospital mortality, but not in those that died by 1 year (3 [3] vs. 2 [1]; P < 0.05 and 2 [2] vs. 1.5 [1]; P = 0.141, respectively). MELD-XI score, on the other hand, was significantly higher in patients with both in-hospital and long-term mortality (12.23 [IQR: 6.53] vs. 9.66 [IQR: 3.81]; P = 0.001 and 10.80 [IQR: 6.31] vs. 9.70 [IQR: 3.70]; P = 0.037, respectively) [Table 3] and [Table 4], respectively]. In univariate analysis, in-hospital cardiac mortality was significantly correlated with MELD-XI score, revised cardiac risk index (Lee) score, cardiac adverse events, serum creatinine level, and serum hemoglobin count (P < 0.05 for all), while 1-year all-cause mortality was significantly correlated with MELD-XI score and hemoglobin count (P < 0.05 for both comparisons), but not to revised cardiac risk index (Lee) score. A multivariate analysis showed that MELD-XI score independently predicted in-hospital all-cause mortality (OR: 1.254 [95% confidence interval (CI): 1.028–1.530]; P < 0.05) and 1-year mortality (OR: 1.258 [95% CI: 1.057–1.498]; P < 0.01). In ROC analysis, a MELD-XI score of >10.70 significantly predicted in-hospital cardiac mortality with a sensitivity of 75.0% and a specificity of 63.2% (AUC: 0.760; 95% CI: 0.640–0.880; P = 0.01) [Figure 1]; a MELD-XI score of >9.87 was associated with 1-year all-cause mortality with a sensitivity of 80% and a specificity of 40.9% (AUC: 0.633; 95% CI: 0.513–0.753; P < 0.05) [Figure 2]. A survival analysis performed between the patients categorized into high (>9.87) and low (≤9.87) MELD-XI score groups showed that the patients with a high MELD-XI score (>9.87) had a significantly worse 1-year survival (log rank test; P < 0.05) [Figure 3].
Figure 1: Receiver operating characteristic analysis of model for end-stage liver disease excluding international normalized ratio score for prediction of in-hospital mortality

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Figure 2: Receiver operating characteristic analysis of model for end-stage liver disease excluding international normalized ratio score for prediction of 1-year all-cause mortality

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Figure 3: Kaplan–Meier curve of 1-year survival based on model for end-stage liver disease excluding international normalized ratio category (>9.87 vs. ≤9.87)

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  Discussion Top


This study has some important findings. First, among patients with high-risk cardiac conditions who underwent elective or urgent noncardiac surgery, MELD-XI score was significantly higher in those with in-hospital cardiac and 1-year all-cause mortality compared to survivors. Second, MELD-XI score independently predicted in-hospital cardiac mortality and 1-year all-cause mortality. Collectively, these results suggest that MELD-XI score is a useful score for predicting prognosis after both elective and urgent noncardiac surgery among patients with high-risk cardiac conditions.

Cardiac risk is an important aspect of noncardiac surgery for both surgeons and patients.[17],[18] On average, 7%–11% of all noncardiac surgical operations are complicated, and mortality rates range between 0.8% and 1.5%,[17] with as much as 42% of all complications being of cardiac origin.[18] Apart from emergent or cardiovascular procedures, several cardiac conditions increase the risk of a noncardiac procedure.[1] However, not all high-risk patients die from or suffer adverse cardiovascular events, with other procedural, anesthetic, and patient-specific factors being operational in the perioperative period or in the long term. Although some high-risk cardiac conditions may be treated and cardiac risk may be reduced,[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] such procedures may not be performed due either to urgency of surgery or presence of multiple/severe comorbidities. Hence, other prognostic tools for advanced risk stratification of patients undergoing noncardiac surgery are needed.

MELD score was originally developed to predict clinical outcomes in liver disease.[4] It was subsequently used in various cardiac conditions.[7],[8],[9] The suggested mechanism by which MELD score predicts mortality in cardiac conditions is reduced forward cardiac output and end-organ perfusion (forward failure) as well as increased central venous pressure leading to hepatic and renal venous congestion (backward failure), which are reflected by increased serum creatinine, total bilirubin, and INR.[35],[36],[37] MELD-XI score, a modification of the original MELD score excluding INR from the model, was developed to determine the prognosis of patients using anticoagulants. MELD-XI score has been successfully tested in various cardiac conditions [11],[12],[13],[14],[15],[16] and critically ill.[38] Although MELD-XI score was tested in cardiac surgery and cardiac transplantation,[11],[12],[16],[39] our study is the first to investigate it for advanced risk stratification of high-risk cardiac patients undergoing noncardiac surgery.

In the present study, MELD-XI score successfully independently predicted both in-hospital cardiac mortality and 1-year all-cause mortality. It was also highly correlated with revised cardiac risk index (Lee) score, which has been shown to accurately predict perioperative cardiac events.[3] When hemodynamic burden of conditions requiring noncardiac surgery is added to high-risk cardiac conditions, overt or subclinical heart failure may develop, resulting in an elevated MELD-XI score. Hence, a higher MELD-XI score in high-risk surgical patients may indicate an even higher cardiac risk. Of note, our study found that MELD-XI score was not correlated with echocardiographic left ventricular ejection fraction (LVEF). However, heart failure may develop in patients with normal LVEF. In support of this view, MELD-XI score was positively correlated with the rates of heart failure (combination of diastolic and systolic failure). In addition, it was significantly and positively correlated with coronary artery disease, severe valvular lesions, and ST segment depression and significantly and negatively correlated with serum hemoglobin count, all of which may also be responsible for cardiovascular dysfunction.

Various studies have reported a range of MELD-XI scores for mortality prediction, and this variability may stem from different inclusion criteria and conditions. We found a MELD-XI cutoff point of 10.70 for in-hospital cardiac mortality, which is in agreement with an almost identical score reported by He et al.[13] However, Wernly et al.[10] and Critsinelis et al.[11] reported much higher cutoff points (12 and 14, respectively) for in-hospital mortality among patients with critical illness and those undergoing LVAD implantation, respectively. Similarly, our MELD-XI cutoff point of 9.87 for long-term all-cause mortality is much lower than those reported by Yang et al.[14] and Spieker et al.[12] (17 and 16, respectively) after LVAD placement and percutaneous mitral valve repair, respectively. He et al.[13] and Wernly et al.[10] reported somewhat lower, albeit still higher, cutoff points (13 and 12, respectively) for prediction of long-term mortality after infective endocarditis and critical illness, respectively. According to our opinion, our MELD-XI cutoff points were lower than previously reported because our patients were at the highest risk of death caused by the risk of noncardiac surgery added to cardiac high-risk conditions, a higher median age (81 years) and a higher rate of heart failure (50%). Hence, lower MELD-XI scores may have predicted short-term and long-term mortality among our patients.

Limitations

This study had some limitations. First, it had a retrospective design. Second, the study population was relatively small because a sizeable portion of patients having high-risk cardiac conditions refuse to undergo noncardiac surgery due to heightened cardiac risk, or some surgeons refuse to operate such patients, particularly when there is no compelling indication for surgery. Furthermore, corrective or palliative cardiac procedures are performed prior to noncardiac surgery in some of patients with high-risk cardiac conditions. Third, we only took into consideration high-risk cardiac conditions; thus, it is unclear how noncardiac factors affected mortality rates. Fourth, although MELD-XI score gives an estimation of both renal and hepatic function, we also did not seek to answer whether MELD-XI score can predict all-cause in-hospital mortality. Fifth, since we only included in-hospital cardiac mortality, 1-year all-cause mortality rate did not include in-hospital noncardiac mortality. Therefore, 1-year all-cause mortality rate was in fact a combination of in-hospital cardiac and postdischarge all-cause mortality rates, which may have created heterogeneity.


  Conclusion Top


MELD-XI score was predictive of in-hospital cardiac and 1-year all-cause mortality independently of high-risk cardiac factors among patients undergoing elective or urgent noncardiac surgery. Hence, MELD-XI score was able to further risk stratify noncardiac surgical candidates which are already at high cardiac risk. This score's role in perioperative risk estimation should be further evaluated by randomized controlled studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, de Hert S, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: Cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: Cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Europ Heart J 2014;35:2383-431.  Back to cited text no. 1
    
2.
Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845-50.  Back to cited text no. 2
    
3.
Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9.  Back to cited text no. 3
    
4.
Cholongitas E, Marelli L, Shusang V, Senzolo M, Rolles K, Patch D, et al. A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation. Liver Transpl 2006;12:1049-61.  Back to cited text no. 4
    
5.
McCaughan GW, Crawford M, Sandroussi C, Koorey DJ, Bowen DG, Shackel NA, et al. Assessment of adult patients with chronic liver failure for liver transplantation in 2015: Who and when? Intern Med J 2016;46:404-12.  Back to cited text no. 5
    
6.
Kamath PS, Kim WR, Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD). Hepatology 2007;45:797-805.  Back to cited text no. 6
    
7.
Kim MS, Kato TS, Farr M, Wu C, Givens RC, Collado E, et al. Hepatic dysfunction in ambulatory patients with heart failure: Application of the MELD scoring system for outcome prediction. J Am Coll Cardiol 2013;61:2253-61.  Back to cited text no. 7
    
8.
Dichtl W, Vogel W, Dunst KM, Grander W, Alber HF, Frick M, et al. Cardiac hepatopathy before and after heart transplantation. Transpl Int 2005;18:697-702.  Back to cited text no. 8
    
9.
Matthews JC, Pagani FD, Haft JW, Koelling TM, Naftel DC, Aaronson KD. Model for end-stage liver disease score predicts left ventricular assist device operative transfusion requirements, morbidity, and mortality. Circulation 2010;121:214-20.  Back to cited text no. 9
    
10.
Wernly B, Lichtenauer M, Franz M, Kabisch B, Muessig J, Masyuk M, et al. Model for end-stage liver disease excluding INR (MELD-XI) score in critically ill patients: Easily available and of prognostic relevance. PLoS One 2017;12:e0170987.  Back to cited text no. 10
    
11.
Critsinelis A, Kurihara C, Volkovicher N, Kawabori M, Sugiura T, Manon M 2nd, et al. Model of end-stage liver disease-excluding ınternational normalized ratio (MELD-XI) Scoring System to Predict Outcomes in Patients Who Undergo Left Ventricular Assist Device Implantation. Ann Thorac Surg 2018;106:513-9.  Back to cited text no. 11
    
12.
Spieker M, Hellhammer K, Wiora J, Klose S, Zeus T, Jung C, et al. Prognostic value of impaired hepato-renal function assessed by the MELD-XI score in patients undergoing percutaneous mitral valve repair. Catheter Cardiovasc Interv 2019;93:699-706.  Back to cited text no. 12
    
13.
He PC, Wei XB, Luo SN, Chen XL, Ke ZH, Yu DQ, et al. Risk prediction in infective endocarditis by modified MELD-XI score. Eur J Clin Microbiol Infect Dis 2018;37:1243-50.  Back to cited text no. 13
    
14.
Yang JA, Kato TS, Shulman BP, Takayama H, Farr M, Jorde UP, et al. Liver dysfunction as a predictor of outcomes in patients with advanced heart failure requiring ventricular assist device support: Use of the Model of End-stage Liver Disease (MELD) and MELD eXcluding INR (MELD-XI) scoring system. J Heart Lung Transplant 2012;31:601-10.  Back to cited text no. 14
    
15.
Abe S, Yoshihisa A, Takiguchi M, Shimizu T, Nakamura Y, Yamauchi H, et al. Liver dysfunction assessed by model for end-stage liver disease excluding INR (MELD-XI) scoring system predicts adverse prognosis in heart failure. PLoS One 2014;9:e100618.  Back to cited text no. 15
    
16.
Assenza GE, Graham DA, Landzberg MJ, Valente AM, Singh MN, Bashir A, et al. MELD-XI score and cardiac mortality or transplantation in patients after Fontan surgery. Heart 2013;99:491-6.  Back to cited text no. 16
    
17.
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.  Back to cited text no. 17
    
18.
Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;307:2295-304.  Back to cited text no. 18
    
19.
Monaco M, Stassano P, Di Tommaso L, Pepino P, Giordano A, Pinna GB, et al. Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: A prospective, randomized study. J Am Coll Cardiol 2009;54:989-96.  Back to cited text no. 19
    
20.
Livhits M, Gibbons MM, de Virgilio C, O'Connell JB, Leonardi MJ, Ko CY, et al. Coronary revascularization after myocardial infarction can reduce risks of noncardiac surgery. J Am Coll Surg 2011;212:1018-26.  Back to cited text no. 20
    
21.
Wong EY, Lawrence HP, Wong DT. The effects of prophylactic coronary revascularization or medical management on patient outcomes after noncardiac surgery-a meta-analysis. Can J Anaesth 2007;54:705-17.  Back to cited text no. 21
    
22.
Huber KC, Evans MA, Bresnahan JF, Gibbons RJ, Holmes DR Jr. Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty. Mayo Clin Proc 1992;67:15-21.  Back to cited text no. 22
    
23.
Sanders RD, Nicholson A, Lewis SR, Smith AF, Alderson P. Peri-operative statin therapy for improving outcomes during and after noncardiac vascular surgery. Cochrane Database Syst Rev 2013;7:CD009971.  Back to cited text no. 23
    
24.
Winchester DE, WenX, Xie L, BavryAA. Evidence ofpre-proceduralstatin therapy a meta-analysis of randomized trials. J Am Coll Cardiol 2010;56:1099-109.  Back to cited text no. 24
    
25.
Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure randomised controlled trials of beta-blockade to prevent peri-operative death in noncardiac surgery. Heart 2014;100:456-64.  Back to cited text no. 25
    
26.
Angeli F, Verdecchia P, Karthikeyan G, Mazzotta G, Gentile G, Reboldi G. B-Blockers reduce mortality in patients undergoing high-risk non-cardiac surgery. Am J Cardiovasc Drugs 2010;10:247-59.  Back to cited text no. 26
    
27.
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2012;33:2451-96.  Back to cited text no. 27
    
28.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on peri-operative cardiovascular evaluation and care for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Peri-operative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007;50:e159-241.  Back to cited text no. 28
    
29.
McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012;14:803-69.  Back to cited text no. 29
    
30.
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death-executive summary: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J 2006;27:2099-140.  Back to cited text no. 30
    
31.
Upshaw J, Kiernan MS. Pre-operative cardiac risk assessment for noncardiac surgery in patients with heart failure. Curr Heart Fail Rep 2013;10:147–156.  Back to cited text no. 31
    
32.
Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, et al. Prevention of torsade de pointes in hospital settings: A scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2010;55:934-47.  Back to cited text no. 32
    
33.
Price LC, Wort SJ, Finney SJ, Marino PS, Brett SJ. Pulmonary vascular and right ventricular dysfunction in adult critical care: Current and emerging options for management: A systematic literature review. Crit Care 2010;14:R169.  Back to cited text no. 33
    
34.
Galie' N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, et al. Guidelines for the diagnosisand treatment of pulmonary hypertension: The taskforce for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009;30:2493-537.  Back to cited text no. 34
    
35.
Inohara T, Kohsaka S, Shiraishi Y, Goda A, Sawano M, Yagawa M, et al. Prognostic impact of renal and hepatic dysfunction based on the MELD-XI score in patients with acute heart failure. Int J Cardiol 2014;176:571-3.  Back to cited text no. 35
    
36.
Ronco C, McCullough P, Anker SD, Anand I, Aspromonte N, Bagshaw SM, et al. Cardio-renal syndromes: Report from the consensus conference of the acute dialysis quality initiative Eur Heart J 2010;31:703-11.  Back to cited text no. 36
    
37.
Nikolaou M, Parissis J, Yilmaz MB, Seronde MF, Kivikko M, Laribi S, et al. Liver function abnormalities, clinical profile, and outcome in acute decompensated heart failure Eur Heart J 2013;34:742-749.  Back to cited text no. 37
    
38.
Wernly B, Lichtenauer M, Vellinga N, Boerma C, Ince C, Kelm M, et al. Model for end-stage liver disease excluding INR (MELD-XI) score is associated with hemodynamic impairment and predicts mortality in critically ill patients. Eur J Intern Med 2018;51:80-4.  Back to cited text no. 38
    
39.
Grimm JC, Shah AS, Magruder JT, Kilic A, Valero V 3rd, Dungan SP, et al. MELD-XI score predicts early mortality in patients after heart transplantation. Ann Thorac Surg 2015;100:1737-43.  Back to cited text no. 39
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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