Early and late outcomes of cardiac operations in patients with cirrhosis: a retrospective survival-rate analysis of 47 patients over 8 years

The importance of liver function assessment before cardiac surgery: A narrative review

The demand for cardiac surgery procedures is increasing globally. Thanks to an improvement in survival driven by medical advances, patients with liver disease undergo cardiac surgery more often. Liver disease is associated with the development of heart failure, especially in patients with advanced cirrhosis. Cardiovascular risk factors can also contribute to the development of both cardiomyopathy and liver disease and heart failure itself can worsen liver function. Despite the risk that liver disease and cirrhosis represent for the perioperative management of patients who undergo cardiac surgery, liver function is often not included in common risk scores for preoperative evaluation. These patients have worse short and long-term survival when compared with other cardiac surgery populations. Preoperative evaluation of liver function, postoperative management and close postoperative follow-up are crucial for avoiding complications and improving results. In the present narrative review, we discuss the pathophysiological components related with postoperative complications and mortality in patients with liver disease who undergo cardiac surgery and provide recommendations for the perioperative management.

Clinical Outcomes of Transcatheter vs Surgical Aortic Valve Replacement in Patients With Chronic Liver Disease: A Systematic Review and Metaanalysis

Background: Chronic liver disease increases cardiac surgical risk, with 30-day mortality ranging from 9% to 52% in patients with Child-Pugh class A and C, respectively. Data comparing the outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with liver disease are limited. Methods: We searched PubMed, Cochrane Library, Web of Science, and Google Scholar for relevant studies and assessed risk of bias using the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) Cochrane Collaboration tool. Results: Five observational studies with 359 TAVR and 1,872 SAVR patients were included in the analysis. Overall, patients undergoing TAVR had a statistically insignificant lower rate of in-hospital mortality (7.2% vs 18.1%; odds ratio [OR] 0.67; 95% confidence interval [CI] 0.25, 1.82; I²=61%) than patients receiving SAVR. In propensity score-matched cohorts, patients undergoing TAVR had lower rates of in-hospital mortality (7.3% vs 13.2%; OR 0.51; 95% CI 0.27, 0.98; I²=13%), blood transfusion (27.4% vs 51.1%; OR 0.36; 95% CI 0.21, 0.60; I²=31%), and hospital length of stay (10.9 vs 15.7 days; mean difference -6.32; 95% CI -10.28, -2.36; I²=83%) than patients having SAVR. No significant differences between the 2 interventions were detected in the proportion of patients discharged home (65.3% vs 53.9%; OR 1.3; 95% CI 0.56, 3.05; I²=67%), acute kidney injury (10.4% vs 17.1%; OR 0.55; 95% CI 0.29, 1.07; I²= 0%), or mean cost of hospitalization ($250,386 vs $257,464; standardized mean difference -0.07; 95% CI -0.29, 0.14; I²=0%). Conclusion: In patients with chronic liver disease, TAVR may be associated with lower rates of in-hospital mortality, blood transfusion, and hospital length of stay compared with SAVR.

Long-Term Outcome of Cardiac Surgery in 1,040 Liver Cirrhosis Patient - Nationwide Population-Based Cohort Study

BACKGROUND

Patients with liver cirrhosis (LC) have a higher risk for cardiac surgery, but population-based long-term follow-up studies are lacking. The aim of this study was therefore to validate the long-term outcome of cardiac surgery in patients with LC.

METHODS AND RESULTS

Data were obtained from Taiwan's National Health Insurance Database, 1997-2011. This study included 1,040 LC patients and 1,040 matched controls without LC. The actuarial survival rate at 1, 5 and 10 years in the LC cohort was 68%, 50% and 41%: significantly lower than that of the control cohort at 81%, 68% and 62% at 1, 5 and 10 years after cardiac surgery. Compared with the matched control cohort, the LC group had a higher risk of liver and heart failure readmission (P<0.001) during the follow-up period. In addition, the LC cohort had a higher risk of liver causes of death than did the control cohort (12.6% vs. 1.2%). In the LC cohort, 51% of deaths were due to hepatocellular carcinoma. And in the LC group, those with valve surgery and advanced cirrhosis had a lower survival rate (P=0.002, P=0.001).

CONCLUSIONS

Even after successful cardiac surgery, long-term outcome is unsatisfactory in LC patients because of the progressive deterioration of liver function.

Revisiting blood transfusion and predictors of outcome in cardiac surgery patients: a concise perspective

In the United States, cardiac surgery-related blood transfusion rates reached new highs in 2010, with 34% of patients receiving blood products. Patients undergoing both complex (coronary artery bypass grafting [CABG] plus valve repair or replacement) and non-complex (isolated CABG) cardiac surgeries are likely to have comorbidities such as anemia. Furthermore, the majority of patients undergoing isolated CABG have a history of myocardial infarction. These characteristics may increase the risk of complications and blood transfusion requirement. It becomes difficult to demonstrate the association between transfusions and mortality because of the fact that most patients undergoing cardiac surgery are also critically ill. Transfusion rates remain high despite the advances in perioperative blood conservation, such as the intraoperative use of cell saver in cardiac surgery. Some recent prospective studies have suggested that the use of blood products, even in low-risk patients, may adversely affect clinical outcomes. In light of this information, we reviewed the literature to assess the clinical outcomes in terms of 30-day and 1-year morbidity and mortality in transfused patients who underwent uncomplicated CABG surgery.

Influence of cirrhosis in cardiac surgery outcomes

Liver cirrhosis has evolved an important risk factor for cardiac surgery due to the higher morbidity and mortality that these patients may suffer compared with general cardiac surgery population. The presence of contributing factors for a poor outcome, such as coagulopathy, a poor nutritional status, an adaptive immune dysfunction, a degree of cirrhotic cardiomyopathy, and a degree of renal and pulmonary dysfunction, have to be taken into account for surgical evaluation when cardiac surgery is needed, together with the degree of liver disease and its primary complications. The associated pathophysiological characteristics that liver cirrhosis represents have a great influence in the development of complications during cardiac surgery and the postoperative course. Despite the population of cirrhotic patients who are referred for cardiac surgery is small and recommendations come from small series, since liver cirrhotic patients have increased their chance of survival in the last 20 years due to the advances in their medical care, which includes liver transplantation, they have been increasingly considered for cardiac surgery. Indeed, there is an expected rise of cirrhotic patients within the cardiac surgical population due to the increasing rates of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, especially in western countries. In consequence, a more specific approach is needed in the assessment of care of these patients if we want to improve their management. In this article, we review the pathophysiology and outcome prediction of cirrhotic patients who underwent cardiac surgery.

Critical care management of the adult patient with congenital heart disease: focus on postoperative management and outcomes

OPINION STATEMENT

Advances in surgical techniques and in the medical management of children with congenital heart disease has increased survival into adulthood, resulting in a population of adults with congenital heart disease now surpassing the pediatric population in numbers. Furthermore, many of the patients will require repeat surgical, catheter-based, procedures and/or obstetrical care in their adult lives, and understanding the specific cardiopulmonary physiology and the involvement of other organ systems is critical to successful intervention. A team approach, with consultants from medical specialties in the setting of an established adult congenital heart center, is the optimal setting for superior outcomes. In this review, we discuss critical care management of the adult congenital heart disease patient in the perioperative period.

Cardiac surgery in patients with liver cirrhosis: Risk factors for predicting mortality

AIM: To evaluate the results of cardiac surgery in cirrhotic patients and to find the predictors of early and late mortality.

METHODS: We included 55 consecutive cirrhotic patients undergoing cardiac surgery between 1993 and 2012. Child-Turcotte-Pugh (Child) classification and Model for End-Stage Liver Disease (MELD) score were used to assess the severity of liver cirrhosis. The online EuroSCORE II calculator was used to calculate the logistic EuroSCORE in each patient. Stepwise logistic regression analysis was used to identify the risk factors for mortality at different times after surgery. Multivariate Cox proportional hazard models were applied to estimate the hazard ratios (HR) of predictors for mortality. The Kaplan-Meier method was used to generate survival curves, and the survival rates between groups were compared using the log-rank test.

RESULTS: There were 30 patients in Child class A, 20 in Child B, and five in Child C. The hospital mortality rate was 16.4%. The actuarial survival rates were 70%, 64%, 56%, and 44% at 1, 2, 3, and 5 years after surgery, respectively. There were no significant differences in major postoperative complications, and early and late mortality between patients with mild and advanced cirrhosis. Multivariate logistic regression showed preoperative serum bilirubin, the EuroSCORE and coronary artery bypass grafting (CABG) were associated with early and late mortality; however, Child class and MELD score were not. Cox regression analysis identified male gender (HR = 0.319; P = 0.009), preoperative serum bilirubin (HR = 1.244; P = 0.044), the EuroSCORE (HR = 1.415; P = 0.001), and CABG (HR = 3.344; P = 0.01) as independent risk factors for overall mortality.

CONCLUSION: Advanced liver cirrhosis should not preclude patients from cardiac surgery. Preoperative serum bilirubin, the EuroSCORE, and CABG are major predictors of early and late mortality.