Open-Heart Surgery in Patients with Liver Cirrhosis: Indications, Risk Factors, and Clinical Outcomes

Abstract

Background: Because of recent advances in cardiopulmonary bypass (CPB) surgery, there are broadened indications to approach patients with a high operative risk. Meanwhile, there is an increasing number of patients with severe liver dysfunction subjected to open-heart surgery. This retrospective study was designed to evaluate the operative indications and clinical outcomes in patients with liver cirrhosis (LC) undergoing open-heart surgery. In addition, determinants influencing their prognosis were assessed. Patients and Methods: Between May 1996 and June 2005, 24 patients with LC underwent CPB open-heart surgery in our institution. The preoperative severity of the LC was determined according to the Child-Pugh classification. Their perioperative data were analyzed. Several perioperative factors were compared by multivariate logistic regression analysis between survivors and nonsurvivors to determine possible risk factors contributing to mortality. Results:There were 14 females and 10 males. Their age ranged from 36 to 72 (mean 53 ± 13) years. Seventeen cases were classified as having Child-Pugh class A LC, 6 as having Child-Pugh class B, and 1 as having Child-Pugh class C LC. All patients underwent CPB surgery. The mean operation time and the cross-clamp time were 160 ± 53 and 90 ± 42 min, respectively. During the first 24 h after the operation, the mean chest tube output was 1,080 ± 320 ml. The mean duration of mechanical ventilation was 32 ± 22 h, and the mean intensive care unit stay was 11 ± 8 days. Sixty-six percent of the patients experienced significant morbidity. Fifty-three percent of the patients with Child-Pugh class A LC and 100% of those with Child-Pugh class B and C LC suffered postoperative complications. The overall mortality rate was 25%. The postoperative mortality rates of the patients with Child-Pugh class A, B, and C LC were 6, 67, and 100%, respectively. Preoperative serum total bilirubin and cholinesterase levels and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values along with CPB time were identified as the important predictors to differentiate between survivors and nonsurvivors by multivariate logistic regression analysis. Conclusions: The Child-Pugh class is associated with hepatic decompensation and mortality after open-heart CPB surgery in patients with LC. Such surgery can be performed safely in patients with a Child-Pugh class A LC. But cardiac interventions using CPB in patients with more advanced LC are associated with high mortality and morbidity rates. The preoperative total plasma bilirubin and cholinesterase concentrations as well as the EuroSCORE along with the CPB time are identified as statistically significant predictors of mortality after open-heart surgery in patients with LC. Our findings indicate that patients with chronic liver disease scheduled for open-heart surgery should be carefully evaluated before the operation and that the CPB duration should be as short as possible.

Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery☆

“…Therefore, only limited data are available to assess specific indicators that identify and stratify those patients who are at high risk for open-heart surgery. Certainly, several reports have shown that open-heart surgery with the use of CPB in patients with liver cirrhosis is associated with adverse clinical outcome and an increased risk for morbidity and mortality, particularly in patients with CTP classes B and C. While the mortality rates of patients in CTP class A were reported to be 10% and less, mortality in CTP class B patients ranges between 0% and 80% and goes up to 100% for CTP class C patients [7][8][9][10][11][12]. These results demonstrate that CTP classes B and C are a heterogeneous group of patients; a more precise definition of the risk in liver cirrhosis patients is thus warranted.…”

“…In fact, liver disease has not been addressed as an independent preoperative risk factor by any of the routinely used and established cardiac surgical risk score models (e.g., European system for cardiac operative risk evaluation (EuroSCORE); except for Pons et al) [3][4][5][6]. Recent evidence only comes from several small studies showing highly increased shortand long-term mortality rates for those patients, who undergo cardiac surgery having end-stage liver disease with liver cirrhosis of Child-Turcotte-Pugh (CTP) classification B or C [7][8][9][10][11][12]. On the other hand, over the past several decades, liver transplantation has emerged as a viable treatment option for patients with end-stage liver disease [13], and the prevalence of concomitant cardiac disease in these patients often carry cardiac risk factors, such as ageing, obesity, diabetes mellitus, hypertension and hyperlipidaemia [14].…”

Systemic abnormalities in liver disease

“…In patients undergoing cardiac surgery, the risk of mortality or complications may be high when a cardiopulmonary bypass is performed on patients with chronic liver disease [223] . In general, the mortality of cirrhotic patients with C-P grade A is low, but that of patients exhibiting C-P grade B for a long period and that of all patients with C-P grade C is high, especially when open heart surgery is performed.…”

Assessment of Bleeding Risk in Patients with Cirrhosis

“…Moreover, the principal causes of death in Child B patients 4/6 were hemorrhage and infection, while the cause of death in Child A and C patients (1/17 and 1/1, respectively) were infection. In this study, platelet count was not different in survivors vs. nonsurvivors, and other parameters related to coagulation and hemostasis were not explored in relation to survival or to frequency of complications [100]. In another study reporting on outcomes after open-heart surgery in 12 patients with cirrhosis, 6 of whom were in Child A and 6 in Child B classes, major complications including hemorrhage and hepatic decompensation were associated with platelet count, while mortality (5/12) was associated with bleeding complications in 3 cases [101].…”