Clinical outcome after cardiac operations in patients with cirrhosis

Outcomes of patients with cirrhosis undergoing non-hepatic surgery: Risk assessment and management

The reported mortality rates in patients with cirrhosis undergoing various non-transplant surgical procedures range from 8.3% to 25%. This wide range of mortality rates is related to severity of liver disease, type of surgery, demographics of patient population, expertise of the surgical, anesthesia and intensive care unit team and finally, reporting bias. In this article, we will review the pathophysiology, morbidity and mortality associated with non-hepatic surgery in patients with cirrhosis, and then recommend an algorithm for risk assessment and evidence based management strategy to optimize post-surgical outcomes.

Early and late outcome of cardiac surgery in patients with liver cirrhosis

Liver cirrhosis is a major risk factor in general surgery. Few studies have reported on the outcome of cardiac surgery in these patients. Herein we report our recent experience in this high-risk patient population according to the Child-Turcotte-Pugh classification and Model for End-Stage Liver Disease (MELD) score. Between January 1998 and December 2004, 27 patients (mean age 58 +/- 10 yr, 20 male) with cirrhosis who underwent cardiac surgery were identified. Patients were in Child-Turcotte-Pugh class A (n = 10), B (n = 11), and C (n = 6) and mean MELD score was 14.2 +/- 4.2. Operative mortality was 26% (n = 7). Stratified mortality according to Child-Turcotte-Pugh class was 11%, 18%, and 67% for class A, B, and C, respectively. No mortality occurred in patients who had revascularization without the use of cardiopulmonary bypass (n = 5). The 1-yr survival was 80%, 45%, and 16% for Child-Turcotte-Pugh class A, B, and C, respectively (P = 0.02). Major postoperative complications occurred in 22%, 56%, and 100% for Child-Turcotte-Pugh class A, B, and C, respectively. Child-Turcotte-Pugh classification was a better predictor of hospital mortality (P = 0.02) compared to MELD score (P = 0.065). In conclusion, our results suggest that cardiac surgery can be performed safely in patients with Child-Turcotte-Pugh class A and selected patients with class B. Operative mortality remains high in class C patients. Careful patient selection is critical in order to improve surgical outcome in patients with cirrhosis.

Stanford type A aortic dissection with Child B liver cirrhosis

Cardiac surgery using cardiopulmonary bypass in patients with advanced liver cirrhosis has been infrequently performed, and reported to be too risky. Aortic dissection accompanied with liver cirrhosis is extremely rare. A 61-year-old woman who had aortic dissection and Child B liver cirrhosis underwent ascending aorta replacement. Liver protection during cardiopulmonary bypass was successfully accomplished by moderate hypothermia and use of an aortic occlusion balloon to maintain sufficient hepatic blood flow.

Preoperative evaluation of patients with liver disease

Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.

Transjugular intrahepatic portosystemic shunt prior to cardiac surgery with cardiopulmonary bypass in patients with cirrhosis and portal hypertension

Because of the increased complications associated with cardiac surgery in patients with cirrhosis and portal hypertension, various preoperative preparations have been utilised. In order to reduce the bleeding risk by decompressing portosystemic collaterals and to correct the fluid shift, we performed transjugular intrahepatic portosystemic shunt (TIPS) in two patients with cirrhosis and portal hypertension prior to major cardiac surgery with cardiopulmonary bypass. Both patients had satisfactory surgical outcome with no bleeding complications. One patient developed hepatic encephalopathy which was managed medically. We believe that preoperative TIPS benefits the patient with cirrhosis and portal hypertension undergoing cardiac surgery by decreasing the major surgical complications through improvement of fluid imbalance and reduction of the bleeding risk. Because of the risks of TIPS, such as encephalopathy and liver failure, preoperative TIPS placement must be reserved for patients with fluid shift or high risk criteria of bleeding.

Risk factors for mortality after surgery in patients with cirrhosis

BACKGROUND & AIMS

Current methods of predicting risk of postoperative mortality in patients with cirrhosis are suboptimal. The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. The aim of this study was to determine the risk factors for postoperative mortality in patients with cirrhosis.

METHODS

Patients with cirrhosis (N = 772) who underwent major digestive (n = 586), orthopedic (n = 107), or cardiovascular (n = 79) surgery were studied. Control groups of patients with cirrhosis included 303 undergoing minor surgical procedures and 562 ambulatory patients. Univariate and multivariable proportional hazards analyses were used to determine the relationship between risk factors and mortality.

RESULTS

Patients undergoing major surgery were at increased risk for mortality up to 90 days postoperatively. By multivariable analysis, only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period.

CONCLUSIONS

MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed. These factors can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.

Open-heart surgery in patients with liver cirrhosis: indications, risk factors, and clinical outcomes

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.

Preoperative evaluation using asialoscintigraphy in patients undergoing cardiac surgery with noncardiac liver cirrhosis

OBJECTIVE

Liver cirrhosis is recognized as one of the risk factors for severe complications after cardiac surgery. However, there are no established methods for risk stratification of the patients with liver cirrhosis (LC) regarding cardiac surgery. We present our experience of preoperative evaluation of liver function using asialoscintigraphy.

METHODS

Between April 1999 and December 2005, we evaluated preoperative liver function using asialoscintigraphy with technetium-99m galactosyl human serum albumin in four cirrhotic patients undergoing coronary artery bypass grafting (n = 2) and valve replacement (n = 2), whose etiologies of LC were alcohol abuse (n = 1) and hepatitis C virus infection (n = 3). They also underwent other tests for preoperative evaluation of liver function, including the indocyanine green (ICG) test.

RESULTS

Asialoscintigraphy revealed that the receptor index and the index of blood clearance in each patient were 0.81/0.73, 0.95/0.5, 0.82/0.62, and 0.97/0.57, respectively. These values closely correlated with the results of the ICG test. All patients were discharged alive from hospital after surgery. However, although one patient who underwent off-pump bypass had an uneventful course, three patients had major complications: pleural effusion (n = 1) and wound infection (n = 2).

CONCLUSION

Asialoscintigraphy is a practical, reliable method that can replace the ICG test for estimating hepatic function for risk stratification of cirrhotic patients undergoing cardiac surgery, whose mortality and morbidity are still high.

Results of living donor liver transplantation in five children with congenital cardiac malformations requiring cardiac surgery

In the pediatric population, the concomitant presentation of end-stage liver disease and congenital cardiac malformation occurs rarely. Determining the surgical priority in these cases is a challenge due to the presence of hemodynamic alterations that increase surgical risks. We examined five cases that received living-donor liver transplantation. In four patients that had congenital heart disease with a left to right shunt, two had cardiac surgery first, one had both heart and liver surgery simultaneously, and one underwent liver transplantation first. Both of the patients that received heart surgery before liver transplantation needed emergency liver transplantation because of post-operative liver failure. All five patients had a good outcome. Meticulous surgery, close monitoring, and adequate volume management, in addition to tailoring management decisions to the patient's specific condition, make it possible to correct both the liver and the heart abnormalities with satisfactory results.

Hyperbilirubinemia after extracorporeal circulation surgery: A recent and prospective study

AIM: To clarify the incidence and nature of posto-perative hyperbilirubinemia in patients after modern extracorporeal circulation, to analyze possible perioperative risk factors, and to elucidate the clinical significance of postoperative hyperbilirubinemia associated mortality and morbidity.

METHODS: Between March 2005 and May 2006, three hundred and eighty six consecutive patients undergoing extracorporeal circulation surgery due to a variety of cardiac lesions were investigated prospectively. The incidence of postoperative hyperbilirubinemia was defined as a serum total bilirubin concentration of more than 51 μmol/L. Several perioperative parameters were compared by logistic regression between hyperbilirubinemia and non-hyperbilirubinemia patients to determine possible risk factors contributing to postoperative hyperbilirubinemia and mortality.

RESULTS: Overall incidence of postoperative hyperbilirubinemia was 25.3% (98/386). In patients with postoperative hyperbilirubinemia, 56.2% reached peak total bilirubin concentration on the first postoperative day, 33.5% on the second day, and 10.3% on the seventh day. Eighty percent of the increase of total bilirubin resulted from an increase of both conjugated and unconjugated bilirubin. Development of postoperative hyperbilirubinemia was associated with a higher mortality (P < 0.01), longer duration of mechanical ventilation (P < 0.05) and longer ICU stay time (P < 0.05). Preoperative total bilirubin concentration, preoperative right atrium pressure, numbers of valves replaced and of blood transfusion requirement were identified as important predictors for postoperative hyperbilirubinemia.

CONCLUSION: Early postoperative hyperbilirubinemia after modern extracorporeal circulation is mainly caused by an increase in both conjugated and unconjugated bilirubin, and is associated with a high mortality. Important contributing factors are the preoperative total bilirubin concentration, preoperative severity of right atrial pressure, numbers of valve replacement procedures, and the amount of blood transfusion requirement during and shortly after surgery. We suggest that postoperative hyperbilirubinemia is a multifactorial process, which is caused by both the impaired liver function of bilirubin transport and the increased production of bilirubin from haemolysis.

Lung Cancer Surgery in Patients With Liver Cirrhosis

BACKGROUND

Few reports have described surgery for lung cancer in patients with liver cirrhosis. The objective of this study was to clarify the efficacy of surgical treatment and evaluate its postoperative outcome.

METHODS

We retrospectively reviewed the medical charts of 17 patients between 1985 and 2005 who were found to have nonsmall cell lung cancer (NSCLC) with liver cirrhosis. The grading of the severity of liver cirrhosis was made according to the Child-Pugh classification.

RESULTS

Four patients were classified as Child-Pugh class A, whereas another 13 patients were classified as Child-Pugh class B. Of these 17 patients, 11 underwent lobectomies, 3 underwent pneumonectomies, and 3 underwent wedge resections. The only patient who experienced hospital death (5.9%) was a male patient with Child-Pugh class B cirrhosis. There were five respiratory-associated postoperative complications including pneumonia, bleeding from the staple line, and prolonged air leak. The morbidity rate was 29.5%. Median duration of chest tube insertion was 6.8 days, and mean volume of pleural effusion was 1,015.0 mL at 3 days total postoperatively. A total of 9 deaths occurred during follow-up (3 from cancer, 4 from hepatic failure, 1 from cardiac causes, and 1 unknown). The overall survival was 87.8%, 57.0%, and 45.6% at 1, 3, and 5 years, respectively. None of the patients experienced morbidity or mortality in Child-Pugh class A, but class B had 30.8% morbidity and 7.6% mortality.

CONCLUSIONS

Surgical treatment may be an acceptable and valuable approach for NSCLC patients who also have low severity liver cirrhosis.

Cardiac surgery in patients with liver cirrhosis

BACKGROUND

Cardiac surgery was infrequently performed in patients with liver cirrhosis, and its clinical outcome has been reported only in small series. We sought to evaluate the clinical outcome of cardiac operation in patients with noncardiac liver cirrhosis.

METHODS

Data were collected by a retrospective case note review. The preoperative, intraoperative, and postoperative variables were recorded. The severity of liver cirrhosis was graded using the Child-Pugh classification.

RESULTS

Between January 1993 and May 2004, 18 patients with liver cirrhosis underwent cardiac surgery at the authors' hospital. Thirteen patients had hepatitis virus infection, and 5 cases were alcohol related. Thirteen patients were classified as Child A cirrhosis, 4 were class B, and 1 was class C. Sixteen patients underwent cardiac surgery with the use of cardiopulmonary bypass, and 2 patients underwent off-pump coronary artery bypass surgery. The overall in-hospital mortality rate was 6% (1 of 18), and there was no death in 5 class B and C cirrhotic patients. The rate of major complication was 39% in class A and 80% in class B and C.

CONCLUSIONS

Although the postoperative complication was common, cardiac operation could be performed safely in patients with mild and advanced liver cirrhosis.

Off-pump coronary artery bypass grafting in a patient with Child class C liver cirrhosis awaiting liver transplantation

We report the case of a Child class C cirrhotic patient who was diagnosed with coronary artery disease in the course of his pretransplantation evaluation. He underwent off-pump coronary artery bypass grafting (OPCAB), which was complicated with acute renal failure. The morbidity and mortality associated with cardiac operation in patients with cirrhosis is discussed, and the potential advantage of OPCAB in this patient population is emphasized.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.

Cardiac Surgery in Children With End-Stage Liver Disease Awaiting Liver Transplantation

BACKGROUND

Cardiac repair for congenital heart disease in children awaiting liver transplantation presents unique therapeutic challenges and dilemmas. We tested the hypothesis that operations in these children requiring cardiopulmonary bypass (CPB) were not associated with prohibitive morbidity and mortality.

METHODS

Over the last 10 years (1994-2004), five infants were identified in our database with end-stage liver disease and awaiting liver transplantation that required cardiac surgery. Primary end point for the study was mortality. Secondary end points included morbidity and time to liver transplantation. The new pediatric end-stage liver disease (PELD) model was used to score liver disease severity.

RESULTS

Three boys and two girls with mean age of 8.6 months (range, 1.5-21 months) and mean PELD of 18.0 (range, 10-29) required CPB for repair. The only early mortality in the series occurred after cardiac arrest during creation of a central shunt. The child expired two days later despite extracorporeal membrane oxygenation support. The patient had important myocardial hypertrophy. All other patients survived and underwent successful liver transplantation.

CONCLUSIONS

Children with significant congenital heart disease awaiting liver transplantation can undergo safe cardiac repair with judicious perioperative support thereby reducing the risks of subsequent liver transplantation.

Abdominal organ injury after cardiac surgery

Gastrointestinal complications occur in about 2.5% of patients undergoing cardiac surgery, are associated with a high mortality (about 33%), and account for nearly 15% (and perhaps increasing) of all postoperative deaths. The various complications and risk factors are reviewed. Splanchnic ischemia prior to, during, and especially postoperatively appears to be an important cause of these complications. In addition, splanchnic ischemia is hypothesized to be one cause of the systemic inflammatory response syndrome and multiorgan failure that may follow cardiac surgery. The physiology of splanchic perfusion and the effects of cardiac surgery, including cardiopulmonary bypass, on it are reviewed. Finally, possible methods to minimize splanchnic ischemia and reduce the incidence of abdominal complications are discussed.