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Ann Thorac Surg 2004;77:500-505
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Clinical outcome after cardiac operations in patients with cirrhosis

^a Department of Surgery, Kurume University, Kurume, Japan

Accepted for publication June 6, 2003.

^* Address reprint requests to Dr Hayashida, Department of Surgery, Kurume University, 67 Asahi-machi, Kurume, Japan 830-0011
e-mail: nobuhiko{at}med.kurume-u.ac.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: To evaluate the clinical outcome after cardiac operations in patients with cirrhosis, a retrospective study was undertaken.

METHODS: Between 1989 and 2003, 18 patients with cirrhosis who underwent cardiac operations were identified. Their preoperative status and postoperative clinical results were assessed.

RESULTS: Ten patients were classified as having Child-Pugh class A cirrhosis, 7 as having class B cirrhosis, and 1 as having class C cirrhosis. Fifteen of 18 patients underwent cardiac surgery using cardiopulmonary bypass, and the remaining 3 patients with class B cirrhosis received coronary artery bypass grafting without cardiopulmonary bypass. In patients undergoing cardiopulmonary bypass, 60% of those with class A cirrhosis and 100% of those with class B cirrhosis and class C cirrhosis had postoperative major complications, including infection, respiratory failure, renal failure, bleeding, and gastrointestinal disorder. One of 3 patients (33%) with class B cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary bypass had major complications. The overall postoperative mortality rate was 17%. Hospital mortality of patients with class A cirrhosis, class B cirrhosis, and class C cirrhosis undergoing cardiopulmonary bypass was 0%, 50%, and 100%, respectively. None of 3 patients with class B cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary bypass died in this study.

CONCLUSIONS: Although the incidence of major complications was high, patients with Child-Pugh class A cirrhosis tolerated cardiac surgery satisfactorily. Patients with more advanced cirrhosis, however, may not be suitable for elective cardiac operations with cardiopulmonary bypass. Although our results are not conclusive, coronary artery bypass grafting without cardiopulmonary bypass can be an alternative therapeutic strategy for patients with advanced cirrhosis requiring surgical revascularization.

	Introduction

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Significant liver dysfunction is still a challenging problem in patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB). It has been documented that preoperative low serum cholinesterase level and elevated bilirubin level are important predictors of prognosis after cardiac operations and ventricular assist device support [1, 2]. In recent studies in which clinical outcomes were assessed in cardiac surgical patients with cirrhosis, postoperative morbidity and morality rates have been reported to be significantly high [3, 4]. However, because the population of cardiac surgical patients with this comorbidity is substantially small and few reports have explored clinical results, definitive recommendations and indications for cardiac surgery are still unknown. In the present study, we conducted a retrospective study to evaluate the clinical outcome after cardiac surgery in patients with cirrhosis.

	Patients and methods

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We reviewed the records of all patients who underwent cardiovascular surgery at Kurume University from February 1989 to January 2003. Eighteen patients were found to have a preoperative history of cirrhosis confirmed by the medical records. The diagnosis of cirrhosis was made either by liver biopsy or signs of portal hypertension with characteristic morphologic changes of the liver and spleen confirmed by ultrasound, computed tomography, and magnetic resonance imaging. Other diagnostic criteria, such as esophageal varices, thrombocytopenia, ascites, encephalopathy, and biologic abnormality, were also entertained. The grading of severity of cirrhosis was made according to the classification of Child-Pugh [5]. The classification is based on the following five factors graded from 1 to 3: presence of encephalopathy, severity of ascites, total bilirubin level, albumin level, and prothrombin time. Patient's cirrhotic status was classified into one of three groups according to the sum of the score (class A, from 5 to 6; class B, from 7 to 9; class B, from 10 to 15). Cardiopulmonary bypass was established with an ascending aortic cannula and either with a single two-stage right atrial cannula or a bicaval venous cannula. Before CPB was initiated, heparin sodium was administered at an initial dose of 300 IU/kg. Additional heparin was administered if the celite-activated clotting time became less than 500 seconds. During CPB, the hematocrit was maintained between 18% and 25%, perfusion flows were kept between 2.4 and 2.8 L · min^-1 · m^-2, and mean arterial pressure was maintained between 50 and 70 mm Hg. Systemic temperature was maintained between 28° and 34°C. In 1 patient with acute aortic dissection (DeBakey type I), ascending aortic replacement was performed under deep hypothermic arrest (20°C) with retrograde cerebral perfusion. In recent 3 patients with Child-Pugh class B cirrhosis, coronary artery bypass grafting without CPB (OPCAB) was performed through a median sternotomy. The technique of OPCAB was reported previously [6]. Heparin was neutralized by continuous intravenous administration of protamine sulfate during a 5-minute period. Minimal dose of catecholamines was used to maintain a cardiac index of greater than 2.0 L · min^-1 · m^-2 and systolic blood pressure of greater than 80 mm Hg after CPB. Packed red blood cells were administered when hematocrit was less than 24%, and platelets were administered when platelet count was less than 2 x 10⁴/µL postoperatively. Mortality is death during a hospitalization for surgery, regardless of length of stay, or within 30 days of hospital discharge. Postoperative complications were determined as follows: A diagnosis of postoperative low output syndrome was made if a patient required either intraaortic balloon pump or dopamine support of greater than 5 µg · kg^-1 · min^-1 for greater than 24 hours in the intensive care unit to maintain a systolic blood pressure greater than 80 mm Hg and a cardiac index greater than 2.1 L · min^-1 · m^-2, despite an adequate preload and correction of any electrolyte disorders. Perioperative myocardial infarction was defined as the appearance of new Q waves or ischemic ST-segment and T-wave changes with a concomitant rise in the MB isoenzyme of creatine kinase greater than 50 IU/L. Cerebrovascular accident was defined as focal brain lesion confirmed by clinical findings or computed tomographic scan. Infection was determined as an occurrence of culture-proven pneumonia, mediastinitis, wound infection, or sepsis. Postoperative renal failure was defined as a requirement of hemodialysis to support renal function, an increase in serum creatinine greater than 1.5 mg/dL, or an occurrence of oliguria (< 0.5 mL · kg^-1 · min^-1) for more than 6 hours postoperatively. Bleeding was determined as a reexploration owing to excessive mediastinal bleeding or a cardiac tamponade requiring an additional drainage. Respiratory failure was determined as a requirement of mechanical ventilatory support for 2 or more total days. Occurrence of postoperative asthma attack requiring intravenous medications and excessive pleural effusion requiring an additional drainage were recorded. Other postoperative complications peculiar to cirrhosis, such as encephalopathy caused by hyperammonemia, hyperbilirubinemia, and gastrointestinal bleeding as a result of varices, were also recorded.

	Results

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Patient characteristics
Preoperative patient characteristics and liver function tests for 18 patients were summarized in Tables 1 and 2. The causes of cirrhosis were viral hepatitis in 12 patients, alcohol related in 3, congestive heart failure in 1, primary biliary cirrhosis in 1, and unknown in 1. Four patients had mild to moderate ascites, and 8 had esophageal or gastric varices preoperatively. Ten patients were classified as having Child-Pugh class A cirrhosis, 7 as having Child-Pugh class B cirrhosis, and 1 as having Child-Pugh class C cirrhosis. A variety of cardiovascular procedures, including coronary artery bypass grafting, valvular surgery, pericardiectomy, and aortic surgery, were performed (Table 3). In patients undergoing CPB, the mean CPB time and the cross-clamp time were 151 + 63 minutes and 98 + 52 minutes, respectively. In 3 patients undergoing OPCAB, single, double, and triple bypass grafting were performed, and the mean duration of myocardial ischemia was 37 ± 17 minutes.

	Comment

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Congestive heart failure owing to myocardial infarction, cardiomyopathy, rheumatic heart disease, or constrictive pericarditis increases hepatic venous pressure and decreases hepatic blood flow, with resulting congestive liver fibrosis and cirrhosis. Multiple medications for cardiac disorders and blood transfusion during prior cardiac surgery may also compromise liver function. Accordingly, a close association between cardiac and liver disorders exists, and we occasionally encounter patients with the pathognomonic features. Despite the circumstances, patients with cirrhosis are less frequently referred for elective open heart surgery because of their considerably compromised health status and decreased life expectancy.

Because the number of patients reported in the literature is small, and morbidity and mortality rates after cardiac surgery using CPB in patients with this comorbidity are considerably high [3, 4], definitive recommendations and indications for operation have not been conclusively shown. Recent studies demonstrated that although the incidence of postoperative complications was high, patients with mild cirrhosis tolerated open heart surgery well [3, 4]. Patients with more advanced cirrhosis, however, had significantly higher mortality rate (50% to 80%) after CPB [3, 4]. Moreover, the health status in such patients remained compromised even well after the operation [3]. Accordingly, it is generally agreed that elective cardiac operations using CPB are contraindicated in patients with moderate to severe cirrhosis (Child-Pugh class B or C cirrhosis). Our study also has shown that the mortality was 60% in patients with moderate to severe cirrhosis undergoing CPB. In contrast, none of the patients with Child-Pugh class B cirrhosis undergoing OPCAB died in this study. It has been well documented that the use of CPB triggers the production and release of numerous vasoactive substances and cytotoxic chemicals that affect coagulopathy, vascular resistance, vascular permeability, fluid balance, and major organ function [11]. Other contributing factors, such as hypothermia, hemodilution, and hypoperfusion during CPB, also may be responsible for the morbidity and mortality after operation [12]. The avoidance of CPB use, therefore, may theoretically improve postoperative clinical outcome by preventing its adverse side effects, particularly in patients with compromised organ function. Although the technique is not indicated in all patients requiring cardiac surgical interventions, OPCAB can be an alternative therapeutic strategy for patients with moderate to severe cirrhosis requiring surgical revascularization. However, because little is known about whether this technique improves postoperative clinical outcome in patients with moderate to severe cirrhosis, further investigations including more patients are required for the universal application.

Similar to earlier reports [3, 4], the incidence of postoperative fluid retention, characterized by edema, ascites, pericardial effusion, and pleural effusion, was considerably high and the management was troublesome in most cases. Poor nutritional status, sodium retention, and portopulmonary hypertension in cirrhotic patients may be responsible for the abnormalities [13]. Several studies have shown that renal responsiveness to atrial natriuretic peptides was blunted despite baseline elevation of its level in cirrhotic patients [14, 15]. The resistance to natriuretic action, which is similarly seen in patients with congestive heart failure [15], may lead to water and sodium retention. Moreover, because biologic activity of endogenous atrial natriuretic peptides has been reported to decrease after CPB [16], the edematous status may worsen after cardiac surgery. Because natriuretic effects of synthetic urodilatin, an atrial natriuretic peptide, have been proven even in cirrhosis with ascites [17], perioperative use of this agent may improve clinical outcome after cardiac operations.

Previous reports have shown that the higher mortality was not attributable to impaired cardiac function, but to an increased susceptibility to infections, gastrointestinal complications, and bleeding [3, 4]. Similar to these reports, the present study also demonstrated the higher prevalence of infections, such as mediastinitis and septicemia, probably related to poor nutritional state and excessive mediastinal bleeding requiring reexploration. In a recent report [1], preoperative levels of serum cholinesterase, a hepatocyte secretion enzyme, have been demonstrated to be an independent predictor of mortality in patients with liver dysfunction undergoing cardiac surgery. Because cholinesterase activity correlates with hepatic protein synthesis rate, the values are considered to be an index of hepatic functional reserve [18]. Markedly lower values of cholinesterase and albumin to globulin ratio observed in our patient population would represent malnutritional status and reduced hepatic functional reserve. Assessment and optimization of perioperative nutritional status thus are essential for an improvement of postoperative clinical outcomes in such patients. In patients with end-stage cardiac failure requiring ventricular assist device, a low preoperative bilirubin level has been shown to be the only significant predictor for survival [2]. In the present study, although the results are not conclusive because of the small sample size, patients with postoperative major complications tended to have higher preoperative bilirubin levels (1.7 ± 0.8 versus 0.9 ± 0.4 mg/dL; p = 0.04). Besides the Child-Pugh score, one must take preoperative bilirubin level per se into consideration for patient selection and perioperative management. Perioperative ammonia concentration also should be controlled meticulously because patients with portal hypertension are particularly prone to develop hyperammonemia [19]. We control its level by eliminating protein from the diet, removing nitrogen from the gastrointestinal tract by cathartics and enemas, and administering intestinal antibiotics.

In summary, although major morbidity was high, patients with Child-Pugh class A cirrhosis tolerated cardiac surgery satisfactorily. In patients with more advanced cirrhosis, such as Child-Pugh class B and C cirrhosis, however, postoperative mortality was unacceptably high, and this patient subgroup may not be suitable for elective cardiac operations with CPB. Although our results are not conclusive because of the small patient number, OPCAB can be an alternative therapeutic strategy for patients with advanced cirrhosis requiring surgical revascularization.

	Acknowledgments

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This work was supported in part by the Grant-in-Aid for Encouragement of Young Scientists, Japan Society for the Promotion of Science (grant A-13770754 and grant A-14770696) and Grant-in-Aid for scientific research (grant C-13671416 and grant C-14571290), Japan.

	References

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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): Nobuhiko Hayashida Hideki Teshima Kazuyoshi Takagi Shigeaki Aoyagi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hayashida, N. Articles by Aoyagi, S. Search for Related Content PubMed PubMed Citation Articles by Hayashida, N. Articles by Aoyagi, S. Related Collections Cardiac - other