Ann Thorac Surg 1999;67:1334-1338
© 1999 The Society of Thoracic Surgeons
Original Articles
Early and late outcome after elective cardiac surgery in patients with cirrhosis
Philippe Bizouarn, MDa,
Antoine Ausseur, MDa,
Pascal Desseigne, MDa,
Yann Le Teurnier, MDa,
Bertrand Nougarede, MDa,
Michel Train, MDa,
Jean Luc Michaud, MDa
a Departments of Anesthesiology and Cardiothoracic Surgery, Hôpital G. et R. Laënnec, Nantes, France
Accepted for publication November 16, 1998.
Address reprint requests to Dr Bizouarn, Service d’Anesthésie-Réanimation, Hôpital G. et R. Laënnec, 44035 Nantes, France
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Abstract
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Background. A prospective study was performed to evaluate the early and late outcome after elective cardiac surgery in patients with cirrhosis.
Methods. All patients who underwent elective cardiac surgery between 1995 and 1997, and were suspected of having a history of cirrhosis, were followed in the intensive care unit (ICU), during hospitalization and after hospital discharge. All patients received high doses of aprotinin during surgery.
Results. Ten patients of Child-Pugh class A and 2 patients of Child-Pugh class B were studied. All patients had signs of portal hypertension, and 11 of 12 patients had thrombocytopenia. In the first 24 h after operation, the median chest tube output was 810 mL (range 350 to 1,500 mL). Median ICU and hospital stays were 3 and 15 days, respectively (range 2 to 10 and 7 to 36 days, respectively). Seven patients experienced postoperative morbidity and 7 patients had significant complications after their hospital discharge. One death occurred in the ICU. Two deaths occurred after hospital discharge and were related to further hepatic damage.
Conclusions. These results suggest that, in patients with mild or moderate cirrhosis, the incidence of significant complications was high after elective cardiac surgery, increasing the length of stay in ICU and overall hospitalization time and compromising the health status, even well after the operation.
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Introduction
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Patients with abnormal preoperative hepatic function who undergo cardiac surgery and cardiopulmonary bypass (CPB) are at substantial risk of postoperative complications [1, 2]. In a recent retrospective study, 100% of patients with Child class B and 25% of those with Child class A cirrhosis have major complications, with an overall mortality rate of 31% [1]. However, all patients with Child class B cirrhosis included in this report underwent urgent or emergency operations, and this study fails to identify the patients with preoperative liver disease who are not identified as having cirrhosis. The aim of the study was to prospectively evaluate the early and late outcome after elective cardiac surgery in patients with hepatic cirrhosis.
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Patients and methods
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From 1995 to 1997, all the patients who underwent elective cardiac surgery with CPB and suspected on admission to the cardiothoracic service to have a history of hepatic cirrhosis were followed prospectively after surgery. When cirrhosis was not confirmed by biopsy, cirrhosis was suspected when the following criteria were present: signs of portal hypertension (esophageal varices or typical gastric lesions) with congestive splenomegaly associated with thrombocytopenia, history of ascites not reported to cardiac dysfunction, suspected etiology, and nonspecific biological abnormalities (hyperbilirubinemia, cold agglutinins). The patients were then classified according to the criteria of Child-Pugh. After induction of anesthesia, a loading dose of 2 million kallikrein inhibiting units (KIU) of aprotinin was infused, followed by an infusion of 500,000 KIU/h until the end of the procedure. Two million KIU of aprotinin was also added to the oxygenator priming solution. The heparinization protocol for CPB included administration of 300 units/kg with intermittent monitoring by the celite-activated coagulation time (ACT) to keep the ACT greater than 800 sec. CPB was conducted using a membrane oxygenator and mild hypothermia with pump flow rate of 2.4 L/min/m2. Patients received packed red blood cells when hematocrit was less than 25%. After weaning from CPB and heparin neutralization with 10 mg of protamine for each 1,000 units of heparin, packed red blood cells and platelets were infused when necessary. Postoperative complications and mortality (in the intensive care unit [ICU] and during hospitalization) were noted. Adverse events occurring after discharge from the hospital were recorded. Information regarding the general health status of the patients and possible cardiac or hepatic events was obtained from their general practitioner or cardiologist.
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Results
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Twelve patients were included in the study. Preoperative characteristics are summarized in Tables 1 and 2. Three patients had a confirmed hepatic cirrhosis by biopsy. Two patients had a history of esophageal variceal hemorrhage. A transjugular intrahepatic portosystemic shunt (TIPS) was placed successfully in one of these patients 1 week before surgery to prevent variceal rebleeding. Three patients had a history of ascites and four patients had preoperative ascites confirmed by echography. All patients had signs of portal hypertension, splenomegaly, and thrombocytopenia (platelet count 57 to 100,000/cm3) was present in 11 of 12 patients. Prothombin time was normal in all patients. A variety of cardiac procedures were performed (Table 3). The median CPB and aortic cross clamp times were 85 min (range 60 to 181 min) and 60 min (range 34 to 143 min), respectively. Weaning from CPB was accomplished without the use of vasopressors in 10 of 12 patients. Hemodynamic stability continued postoperatively in 11 of 12 patients. In the first 24 h after operation, the median chest tube output was 810 mL (range 350 to 1,500 mL); 6 patients received packed red blood cells (2 to 3 units), and 7 patients received platelets. Median duration of mechanical ventilation was 21 h (range 8 to 240 h). Median ICU and hospital stays were 3 and 15 days, respectively (range 2 to 10 and 7 to 36 days, respectively). Postoperative and late complications are summarized in Tables 3 and 4. Seven patients experienced postoperative morbidity and 7 patients had significant complications after their hospital discharge. One death occurred in the ICU 10 days after surgery and was attributable to poor cardiac performance and further hepatic damage in a patient proposed for liver transplantation. Nine patients were still alive at 6 months, and 7 of 10 patients were alive at 1 year.
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Comment
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This study showed that complication rates after elective cardiac surgery were high in this population of patients with minimally impaired liver function. Late outcome was characterized by persistent hepatic dysfunction, responsible for two deaths in patients with Child class A cirrhosis. These results are in agreement with those presented in a recent study, where postoperative complications occurred in 2 of 8 patients with Child class A cirrhosis [1]. No deaths occurred in either study in Child class A patients during the hospital stay. Similar to the earlier report, the Child class B patients seemed to have a higher complication rate than the Child class A patients. However, no definitive conclusion could be drawn from these results because of the small number of patients included in both studies. The major difference between the reported study and the present one is that the present study included analysis of complications that occurred after hospital discharge (up to 26-month follow-up). An increase susceptibility to infection noted elsewhere [1], and confirmed in this study, could be due in part to poor nutritional status often present in patients with cirrhosis. However, nutritional status was not studied in this report, and further studies are necessary to confirm this hypothesis or to identify other factors that could influence infectious complications occurring in such patients. For patients with hepatic dysfunction, problems with hemostasis can be expected because of thrombocytopenia, platelet dysfunction, decreased hepatic production of coagulation factors, fibrinolysis, and portal hypertension [3]. In the present study, mediastinal bleeding and blood requirements were lower than those reported by other studies [1, 2]. The use of aprotinin in all patients could explain the blood-saving benefits for these patients with preoperative thrombocytopenia. High-dose aprotinin was used because it has been shown to reduce postoperative blood loss in cardiac surgical patients [4] and in liver transplantation [5]. However, the risk of thrombosis or thromboembolism must be evaluated if large doses of antifibrinolytics are given in patients with complicated coagulopathy due to liver disease [6]. Although the requirements for packed red blood cells and platelets are not different in patients undergoing liver transplantation with veno-venous bypass and receiving either small-dose aprotinin or normal saline, the use of cryoprecipitates and fresh-frozen plasma is found to be higher in the control group [7]. In this study, fibrinolysis is not completely eliminated, and hypercoagulation and the risk of intravascular clotting is avoided as demonstrated by the thromboelastograph data [7]. No thrombotic complications were noted in the present study. However, prospective trials are needed to determine the minimal effective doses of antifibrinolytics in patients with hepatic cirrhosis undergoing cardiac surgery with extra corporeal circulation (ECC). The risk of gastrointestinal hemorrhage after cardiac surgery remains in patients with esophageal varices. However, no gastrointestinal bleeding was observed in the present study. In one patient, a TIPS was placed before the operation. The TIPS has proved remarkably successful at controlling portal hypertension and bleeding in cirrhotic patients [8, 9]. Nevertheless, this invasive procedure cannot be proposed routinely because of the high incidence of early and late complications (shunt thrombosis, encephalopathy [9, 10], and the hemodynamic variations: increase in cardiac output and systemic vascular resistance) [11, 12] after TIPS placement. The risk of further hepatic damage during CPB to an already compromised liver must also be a concern. Hepatic dysfunction developed in 3% of patients in a population of 3,041 adult patients with normal preoperative liver function who consecutively underwent open heart surgery [13]. Determinants of hepatic dysfunction based on univariate analysis were sex, New York Heart Association class, type of surgery, operation times, low cardiac output syndrome, cardiac arrest, presence of hematomas, and number of blood transfusions [13]. Patients with hepatic dysfunction, defined as the presence of jaundice associated with an elevated serum bilirubin above 3 mg/dL, experienced a much higher mortality rate (11.4%) compared with the control group in this study [13]. Although microembolism and free radicals undoubtedly contribute to liver damage [14], changes in hepatic blood flow during CPB may contribute to hepatic dysfunction. Total hepatic blood flow is reduced but is better maintained by high pump flow than by low pump flow rates [15]. Hypothermic CPB may benefit the hepatic circulation, although the additional advantages usually gained by the use of pulsatile perfusion may be partly lost when hypothermia is combined with a high pump flow rate [15]. For patients with portal hypertension, an increased proportion of the total hepatic blood flow is supplied by the hepatic artery. Therefore, a decrease in arterial pressure or arterial oxygenation is more likely to produce further hepatic damage in these patients as compared with normal patients [3]. In the present study, further hepatic dysfunction was observed in 4 patients in the immediate period after the operation, but was clinically significant in only 2 patients (multiple organ dysfunction syndrome and severe ascites). Further studies are necessary to identify the cirrhotic patients with portal hypertension at risk of developing ascites or severe hepatic dysfunction after cardiac surgery.
In conclusion, these results suggest that, in patients with mild or moderate cirrhosis, the incidence of significant complications was high after elective cardiac surgery, increasing the length of stay in ICU and overall hospitalization time (ie, cost). The health status remained compromised even well after the operation because of persistent hepatic dysfunction. Other studies are required before giving definitive recommendations on the opportunity to perform cardiac surgery in such patients.
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References
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|---|
-
Klemperer J.D., Ko W., Krieger K.H., et al. Cardiac operations in patients with cirrhosis. Ann Thorac Surg 1998;65:85-87.[Abstract/Free Full Text]
-
Ota T., Okamura S. Perioperative management in patients with liver cirrhosis undergoing open heart surgery. Kyobu Geka 1996;49:916-920.[Medline]
-
Morris J.J., Hellman C.L., Gawey B.J., et al. Three patients requiring both coronary artery bypass surgery and orthotopic liver transplantation. J Cardiothorac Vasc Anesth 1995;9:322-332.[Medline]
-
Laupacis A., Fergusson D., International Study of Perioperative Transfusion Investigators. Drugs to minimize perioperative blood loss in cardiac surgery: metaanalysis using perioperative blood transfusion as the outcome. Anesth Analg 1997;85:1258-1267.[Abstract]
-
Grosse H., Lobbes W., Frambach M., et al. The use of high dose aprotinin in liver transplantation: the influence on fibrinolysis and blood loss. Thromb Res 1991;63:287-297.[Medline]
-
Sopher M., Braunfeld M., Shakelton C., Busuttil R.W., Sangwan S., Csete M. Fatal pulmonary embolism during liver transplantation. Anesthesiology 1997;87:429-432.[Medline]
-
Marcel R.J., Stegall W.C., Arnold J.C., et al. Continuous small-dose aprotinin controls fibrinolysis during orthotopic liver transplantation. Anesth Analg 1996;82:1122-1125.[Abstract]
-
Haskal Z.J., Pentecost M.J., Soulen M.C., et al. Transjugular intrahepatic portosystemic shunt stenosis and revision: early and midterm results. Am J Roentgenol 1994;163:439-444.[Abstract/Free Full Text]
-
LaBerge J.M., Ring E.J., Gordon R.L., et al. Creation of transjugular intrahepatic portosystemic shunts with the Wallstent endoprothesis: results in 100 patients. Radiology 1993;187:413-420.[Abstract/Free Full Text]
-
Sanyal A.J., Freedman A.M., Shiffman M.L., Purdum P.P., Luketic V.A. Portosystemic encephalopathy following transjugular intrahepatic portosystemic shunt (TIPS): results of a prospective controlled study. Hepatology 1994;20:46-55.[Medline]
-
Wong F., Sniderman K., Liu P., Allinida Y., Sherman M. Transjugular intrahepatic portosystemic stent shunt: effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites. Ann Intern Med 1995;122:816-822.[Abstract/Free Full Text]
-
Azoulay D., Castaing D., Dennison A., Martino W., Eyraud D. Transjugular intrahepatic portosystemic shunt worsens the hemodynamic circulatory state of the cirrhotic patient: preliminary report of a prospective study. Hepatology 1994;19:129-132.[Medline]
-
Michalopoulos A., Alivizatos P., Geroulanos S. Hepatic dysfunction following cardiac surgery: determinants and consequences. Hepatogastroenterology 1997;44:779-783.[Medline]
-
Desai J.B., Ohri S.K. Gastrointestinal damage following cardiopulmonary bypass. Perfusion 1990;5:161-168.[Free Full Text]
-
Mathie R.T. Hepatic blood flow during cardiopulmonary bypass. Crit Care Med 1993;21(Suppl 2):72-76.
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Top
Abstract
Introduction
