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Ann Thorac Surg 1998;65:85-87
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Cardiac Operations in Patients With Cirrhosis

Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical Center, New York, New York, USA

Accepted for publication July 9, 1997.

Dr Klemperer, Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical College, 525 E 68th St, New York, NY 10021.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background. A retrospective review was performed to determine the outcome after cardiac operations in patients with a documented history of noncardiac cirrhosis.

Methods. The charts of patients admitted to the cardiothoracic surgical service between 1990 and 1996 were reviewed, and 13 patients with a preoperative history of cirrhosis were identified. The severity of preoperative liver disease was graded according to the criteria of Child.

Results. Most of the cases of cirrhosis were alcohol-related. Eight patients were classified as having Child class A and 5 as having Child class B cirrhosis. One hundred percent of patients with Child class B and 25% of those with Child class A cirrhosis had major complications. The postoperative chest tube output and transfusion requirements of these patients were approximately three times higher than average. The overall perioperative mortality rate was 31%. In patients with Child class B cirrhosis, the mortality rate was 80%. No patient with Child class A cirrhosis died. Deaths were related to gastrointestinal and septic complications, and not to cardiovascular failure.

Conclusions. These findings suggest that patients with minimal clinical evidence of cirrhosis can tolerate cardiopulmonary bypass and cardiac surgical procedures, whereas those with more advanced liver disease should not be offered operation.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients with cirrhosis are known to have high complication and mortality rates after major abdominal operations [1][2]. In this report, we evaluate the outcome after cardiac operations in patients with cirrhosis who were operated on at our institution over a 6-year period.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
From 1990 to 1996, the charts of those patients admitted to the cardiothoracic surgical service who were documented as having a history of liver disease, determined from computer coding in the medical records department data bank, were screened. A diagnosis of cirrhosis was established from the admission medical history and the severity was graded according to the classification of Child [3]. Patients with abnormalities of preoperative liver function tests who did not have a documented history of cirrhosis were not included. Thirteen patients were identified and form the basis for this report. Charts were reviewed in detail with respect to the preoperative, intraoperative, and postoperative course. Cardiopulmonary bypass, myocardial protection, and surgical techniques were performed as described previously [4]. Postoperative complications were classified as neurologic (stroke, encephalopathy), pulmonary (pneumonia, ventilator dependence greater than 48 hours, respiratory failure), infectious (deep sternal wound infection, septicemia), gastrointestinal (upper or lower gastrointestinal bleed, acute inflammatory conditions), and renal (need for new dialysis). Mortality was defined as death occurring during the hospitalization after operation.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Of the 13 patients identified with a preoperative history of cirrhosis, 10 cases were alcohol-related, 2 were viral postnecrotic, and 1 was due to primary biliary cirrhosis. Five of the 13 patients had moderate to advanced liver disease by Child’s criteria (class B). Four patients had a history of esophageal variceal hemorrhage, including 1 patient who had undergone a portacaval shunt procedure. Other chronic illnesses are listed in Table 1. A variety of cardiac procedures were performed, consisting of a nearly equal number of bypass and valve operations, less than a third of which were considered elective (Table 2). The mean cardiopulmonary bypass and aortic cross-clamp times were 102 and 62 minutes, respectively.

Fifty-four percent of the patients (7 of 13) experienced significant postoperative morbidity. The 5 patients with Child class B cirrhosis had multiple postoperative complications and correspondingly high postoperative intensive care unit and hospital stays (Table 2). As shown in Table 3 perioperative complications occurred in 25% of patients with Child class A cirrhosis, and except for a 76-year-old man who had a postoperative stroke, this group did not require unusually long intensive care unit or hospital stays. The 4 deaths, none of which were attributable primarily to poor cardiac performance, occurred in patients with moderate impairment of hepatic functional reserve (Table 3). The postoperative courses of these patients were characterized by progressive clinical deterioration associated with major infectious or hemorrhagic complications culminating in hepatic and multisystem organ failure. All patients with Child class A cirrhosis survived the operation and were discharged from the hospital.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

The number of patients identified in this report is small and may reflect an awareness (despite the absence of published data) of the high operative risk and a reluctance to offer operation to patients with a history of cirrhosis. All the patients with Child class B cirrhosis included in this report underwent urgent or emergency operations. This retrospective review also would have failed to identify those patients with limited liver disease who were not identified as having cirrhosis on the preoperative medical history. It is expected, however, that such patients would be at a comparable risk to those patients with Child class A cirrhosis. The small sample size precludes formal statistical analysis or definitive recommendations. However, these results suggest that a diagnosis of moderate to advanced cirrhosis (Child class B or C) is associated with an unacceptable operative risk and could be considered a contraindication to the performance of cardiopulmonary bypass procedures. If in individual cases, an urgent or emergency operation is deemed unavoidable, optimization of preoperative hepatic status and maximization of pharmacologic and technical measures to limit postoperative blood loss are warranted. Patients with a history of liver disease and minimal or no clinical evidence of cirrhosis appear to tolerate cardiac operations satisfactorily, and our policy would be to continue to offer operations to such patients.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Doberneck RC, Sterling WA, Allison DC Morbidity and mortality after operation in nonbleeding cirrhotic patients. Am J Surg 1983;146:306-309.[Medline]
2. Aranha GV, Sontag SJ, Greenberg HB Cholecystectomy in cirrhotic patients: a formidable operation. Am J Surg 1982;143:55-60.[Medline]
3. Child CG, III The liver and portal hypertension. Philadelphia: Saunders, 1964:50.
4. Ko W, Krieger KH, Isom OW Cardiopulmonary bypass procedures in dialysis patients. Ann Thorac Surg 1993;55:677-684.[Abstract/Free Full Text]
5. Helm R, Klemperer JD, Rosengart TR, et al. Intraoperative autologous blood donation preserves red cell mass but does not decrease postoperative bleeding. Ann Thorac Surg 1996;62:634-645.
6. Toyoda Y, Okada T, Sugimoto M, et al. Successful surgical treatment of cardiac cirrhosis. Tricuspid surgery and plasma exchange. J Cardiovasc Surg 1996;37:305-307.[Medline]
7. Kay JH Surgical treatment of tricuspid regurgitation. Ann Thorac Surg 1992;53:1132-1133.[Abstract/Free Full Text]
8. Dunton RF, Karlson KJ, Leonardi HK, Jenkins RL, Berger RL Coronary artery bypass grafting in patients with transplanted livers. Ann Thorac Surg 1994;58:1054-1058.[Abstract/Free Full Text]
9. Krasna MJ, Flancbaum L, Trooskin SZ, et al. Gastrointestinal complications after cardiac surgery. Surgery 1988;104:773-780.[Medline]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John D. Klemperer Wilson Ko Karl H. Krieger Todd K. Rosengart Nasser K. Altorki Samuel Lang O. Wayne Isom Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Klemperer, J. D. Articles by Isom, O. W. Search for Related Content PubMed PubMed Citation Articles by Klemperer, J. D. Articles by Isom, O. W.