Pre-existing heart failure subtype and in-hospital mortality in liver transplantation: a nationwide analysis

Background: Heart failure (HF) is increasingly encountered in liver transplant candidates, yet the influence of HF phenotype on perioperative outcomes remains unclear. We evaluated the association between pre-existing HF subtype and in-hospital mortality among liver transplant hospitalizations. Methods: We conducted a retrospective cohort study of the National Inpatient Sample, 2016-2022. Adult liver transplant hospitalizations were stratified into no HF, chronic diastolic HF, and chronic systolic HF (surrogates for HF with preserved and reduced ejection fraction, respectively). The primary outcome was in-hospital mortality; secondary outcomes included acute kidney injury, acute HF, cardiogenic shock, cardiac arrest, discharge disposition, length of stay, and hospital charges. Survey-weighted multivariable logistic regression was adjusted for demographics, comorbidities, and hospital characteristics. Results: Among 53,910 weighted hospitalizations, 98.1% had no HF, 1.5% had chronic diastolic HF, and 0.4% had chronic systolic HF. Patients with chronic diastolic HF were older with a greater comorbidity burden, including hypertension, diabetes, arrhythmias, and renal failure (all p<0.01). Unadjusted in-hospital mortality was higher in chronic diastolic HF (5.7%) and chronic systolic HF (7.0%) than in no HF (2.9%; p=0.03), as were acute kidney injury, cardiac arrest, length of stay, and charges. After adjustment, neither chronic diastolic HF (adjusted odds ratio 1.6, 95% confidence interval 0.7-3.4) nor chronic systolic HF (2.1, 0.7-6.7) was independently associated with mortality. Conclusions: Pre-existing HF is associated with worse unadjusted outcomes in liver transplant hospitalizations, but HF subtype is not independently associated with in-hospital mortality after adjustment. Comorbidity burden, rather than HF phenotype, appears to drive mortality risk in this highly selected population.