Cardio-hepatorenal interactions have been a focus of attention in heart failure for many years, and the model of end-stage liver disease (MELD) and its variations, including the MELD-XI, have been useful for prediction of poor outcome in adult patients with decompensated heart failure (1). In this issue of the Journal, Egbe et al. (2) highlight the prognostic strengths of the current MELD-XI score in patients with Ebstein anomaly while addressing some of its limitations. They also introduce modifications to enhance a MELD-based predictive risk model for patients with Ebstein anomaly (3). The authors highlight the implications of hepatorenal dysfunction in Ebstein anomaly using the MELD-XI scoring system, and its echocardiographic correlation with right-sided cardiac chambers. The utility of MELD-based risk assessment has been previously described in patients with congenital heart disease (CHD) to prognosticate “noncardiac” organ system dysfunction (3, 4, 5). To better understand the utility of MELD score (and its variations) in CHD, one has to review the historical context of why the MELD score and its variations were implemented for prognostication and utilization for organ allocation.

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