Long-Term Follow-Up in Liver Transplantation and Combined Cardiac Surgery: Validation and Refinement of the LT+CS Risk Score Using Advanced Machine Learning.
Journal:
Journal of the American College of Surgeons
Published Date:
Feb 13, 2026
Abstract
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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