Left ventricular mass predicted complications in children with cirrhosis awaiting transplant

Design

Comparative cohort study with echocardiography, morphometry and histopathology, with ROC analysis

Population

226 children with cirrhosis and 160 without, listed for liver transplantation 2011 to 2021

Primary outcome

Waitlist decompensation, serious post-transplant adverse events and mortality, by left ventricular mass index

Effect

Left ventricular hypertrophy in about 25% (OR 6.9, 95% CI 3 to 16); index thresholds 88, 91 and 95 g per m2.7 for decompensation, serious events and death

This study compared echocardiography, morphometry and histology in 226 children with cirrhosis and 160 without, all listed for liver transplantation between 2011 and 2021. The aim was to define a reliable echocardiographic marker of cirrhotic cardiomyopathy for predicting perioperative adverse events.

Left ventricular mass was higher in cirrhosis on echocardiography and at necropsy, and about 25% had hypertrophy (OR 6.9, 95% CI 3 to 16). In children with cirrhosis, left ventricular mass index correlated with vasoactive needs during transplant. Values of 88, 91 and 95 g per m2.7 or more were independently associated with waitlist decompensation, serious post-transplant adverse events and death, respectively, after adjusting for PELD-Cr or MELD, bilirubin and INR. Combining the index with PELD-Cr/MELD discriminated decompensation and serious adverse events better than the score alone; for death all models performed alike.

The thresholds were derived in the same cohort and need external validation. It suggests a simple, available test to add to risk assessment in children being considered for transplant.

• About 25% of children with cirrhosis had left ventricular hypertrophy (OR 6.9 vs controls).
• Left ventricular mass index of 88 to 95 g per m2.7 or more was associated with decompensation, serious adverse events and death.
• Adding the index to PELD-Cr/MELD improved discrimination of decompensation and serious events.
• For death, the three models performed comparably.
• Consider echocardiographic assessment of ventricular mass in children with cirrhosis, pending external validation.

Why it matters

Standard scores such as PELD-Cr and MELD do not capture the heart, which is where many perioperative problems arise.

Don't overread it

Thresholds were derived and tested in the same cohort, so performance in other centres is unknown.

The statistics, in plain English

Thresholds chosen to give the best split in one dataset tend to look better there than in a new group. The finding that the index plus PELD-Cr/MELD beat the score alone is encouraging, but it needs testing in a separate cohort.

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