End Stage Liver Disease Models and Ooutcomes in Pediatric Patients Supported With Short-Term Continuous Flow Ventricular Assist Devices
Supervisor / Principle Investigator:
Darren H. Freed
Sabin J. Bozso
MD Class of 2020
Introduction: Short-term continuous flow VADs (STCF-VAD) are increasingly being utilized for mechanical support (MS) in the pediatric population. End-stage liver disease (ELD) models have been associated with mortality and morbidity in adult patients on MS. We sought to determine the relationship between outcomes in pediatric patients on STCF-VADs and 4 ELD models: MELD-XI, MELD-XI for those >1 year, PELD, and a novel score, Pediatric MELD-XI (PMELD).
Methods: All pediatric patients supported with STCF-VADs, between June 2009 and December 2016 were included. Adverse outcomes, including major bleeding and neurological dysfunction were defined by PEDIMACs criteria. The MELD-XI, PELD, and PMELD score were calculated and their association with adverse events and a composite measure of death, major bleeding and neurological dysfunction was analyzed.
Results: Of 33 patients included, median age was 0.58 years (IQR 0.11-4.31), median weight was 8.0 kg (IQR 3.8-15.9), 52% had congenital heart disease, and 52% were male. For device strategy, 55% were on LVADs, 18% RVADs, and 24% BiVADs. In total, 76% patients experienced one of the 3 adverse events, with 76% experiencing a major bleed, 24% with neurological dysfunction, and 15% dying while on STCF-VAD support. The median MELD-XI score was 11.2 (IQR 9.4-29.9), MELD-XI (>1yr) 9.4 (IQR 9.4-22.9), PELD 6.0 (IQR 4.0-13.7) and PMELD -14.7 (IQR -18.8 - -12.2). A higher MELD-XI for all ages was significantly associated with death on device (31.52 vs. 10.24, p=.049) while a trend was seen for increased MELD-XI being associated with a major bleeding event (13.80, p=.054) and having any composite endpoint for all ages (13.80, p=.054). In addition, there was a trend towards a higher PMELD being associated with death (-12.87, p=.053). Lastly, there was no association with the models and any neurological events.
Conclusion: ELD models, which incorporate various measurements of end organ function, were not associated with any neurological events. However, the MELD-XI was significantly associated with death in patients of all ages and a trend can be seen with having a major bleeding event or any of the composite endpoints. These results suggest that ELD models may be limited in their ability to predict outcomes in this patient population. However, given the small patient numbers further work in a larger population are required to determine if the findings in this study hold true.