Do patients with liver cirrhosis undergoing cardiac surgery have acceptable outcomes?☆

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with liver cirrhosis have acceptable outcomes after undergoing cardiac surgery. Altogether 97 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. One prospective and another eight retrospective studies involving adult population of patients with liver cirrhosis undergoing various cardiac surgical procedures were selected. In these studies, the overall mortality was 17.1% and combined mean mortality for Child-Pugh class A, B and C was 5.2%, 35.4% and 70%, respectively. The major morbidity ranged from 20 to 60% in group A and 50 to 100% in the patients with more advanced hepatic disease. Some studies have demonstrated that thrombocytopenia, decreased serum cholinesterase and high preoperative total bilirubin levels are significantly associated with worse clinical outcomes. These studies, although with small samples, collectively demonstrate that patients with Child-Pugh class A cirrhosis tolerated cardiac surgical procedures with a mild increase in mortality and morbidity. However, the risk of mortality in patients with Child-Pugh class B and C or MELD score>13 is extremely high. Nevertheless, even if these patients underwent successful surgery, their long-term survival was significantly poorer and their health status remains compromised even well after cardiac surgery because of persistent liver dysfunction.

Characteristics of Inoperable Patients with Severe Aortic Valve Stenosis —In the Era of Transcatheter Aortic Valve Replacement

“…24) Patients categorized as CHILD classification B and C had a significantly high 30-day mortality (33% and 40%, respectively) compared with CHILD A (20%). Modi, et al reported estimated mortality rates of 5% for patients categorized as CHILD A, 32% for CHILD B, and 67% for CHILD C. 25) Postoperative liver dysfunction, coagulation abnormalities, and difficulty in intravascular volume management would be the reasons for the worse outcome in patients with liver cirrhosis. 24) Frailty has been recently recognized as a significant factor to be taken into account when selecting patients for TAVR.…”

Perioperative Risk Assessment and Management of Cirrhotic Patients

“…Historically associated with a very high mortality [97,134], with Bhangui et al in 2012 referring to several studies [209][210][211], and was corroborated by a meta-analysis by Modi et al of nine cardiac surgery trials [205].…”

Surgery in a Patient with Liver Disease

“…Revascularization without the use of cardiopulmonary bypass may be a lower risk but in these decompensated patients long-term survival is significantly poor and health status is compromised even well after cardiac surgery. 24 …”