HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Cornelia Carr Jatin Desai Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carr, C. Articles by Desai, J. Search for Related Content PubMed PubMed Citation Articles by Carr, C. Articles by Desai, J. Related Collections Minimally invasive surgery

Ann Thorac Surg 2004;78:1460-1462
© 2004 The Society of Thoracic Surgeons

---

Case report

OPCAB Surgery in a Cirrhotic Hepatocellular Carcinoma Patient Awaiting Liver Transplant

^a King's College Hospital, Denmark Hill, London, United Kingdom

Accepted for publication July 10, 2003.

^* Address reprint requests to Dr Carr, Department of Cardiothoracic Surgery, King's College Hospital, London SE5 9RS, UK
noahalkh{at}talk21.com

	Abstract

Top Abstract Introduction Comment References

 
Cirrhosis was once thought of as an absolute contraindication to cardiac surgery with the risk of liver decompensation following the use of cardiopulmonary bypass. With the advent of off-pump coronary artery bypass grafting, the possibility of reducing the risk of decompensation may make this type of surgery suitable for patients who will eventually undergo orthotopic liver transplantation. We present the strategy used in a patient with multifocal hepatocellular carcinoma and cirrhosis who underwent coronary artery bypass grafts for unstable angina, in order to allow him to undergo liver transplantation at a future date.

	Introduction

Top Abstract Introduction Comment References

 
Liver cirrhosis poses particular problems for cardiac surgery with the risk of hepatic dysfunction and even fulminant hepatic coma and death. The presence of significant coronary artery disease had been thought of as an absolute contraindication to orthotopic liver transplantation (OLT): increased risk of intraoperative myocardial infarction during OLT, and coronary artery bypass grafting (CABG) with end-stage liver disease had been associated with a poor outcome [1, 2]. Previous attempts to solve this problem have involved combined sequential CABG and OLT [3].

We discuss a patient with cirrhosis and hepatocellular carcinoma who was suitable for OPCAB surgery where avoiding cardiopulmonary bypass may have reduced the risk of potentially fatal liver decompensation. We also describe the operative maneuvers to minimize the risk of postoperative bleeding.

A 56-year-old man was admitted with unstable angina, with a history of two previous myocardial infarctions. He was an insulin-dependent diabetic with cirrhosis secondary to alcohol abuse and had several esophageal variceal bleeds in the past. Cardiac catheter demonstrated severe triple vessel disease with a blocked left anterior descending artery (LAD), tight ostial circumflex, ostial diagonal, and proximal right coronary artery stenoses. Echocardiogram illustrated well preserved left ventricular function.

Preoperative workup had revealed deranged liver function tests (Table 1) and a reduced platelet count (50 x 10⁹/L). Ultrasound and computerized tomography (CT) of the liver illustrated two contrast enhancing masses in a cirrhotic liver: a 2.5-cm lesion in segment 4 with a central scar and a 1-cm lesion in segment 6. Hepatitis serology was negative and -fetoprotein was not elevated. He had cirrhosis diagnosed 12 years previously (by biopsy) and his last variceal bleed was 4 years ago.

His reduced platelet count had previously been diagnosed as secondary to his chronic liver disease. He was transfused 2 pools of platelets immediately preoperatively and depending on the repeat full blood count during surgery, further transfusion would be titrated.

Following median sternotomy bilateral skeletonized internal thoracic arteries were harvested leaving the pleurae intact on both sides in order to minimize blood loss postoperatively, due to the reduced platelet count and decreased clotting product production (intraoperative platelet count 64 x 10⁹/L). Long saphenous vein was harvested from the leg using a minimally invasive "stripper" technique.

Following half-dose heparin OPCAB surgery was performed using the Octopus 3 (Medtronic Inc, Minneapolis, MN) stabilizer and intracoronary shunts (Flo-thru; Biovascular Inc, St Paul, MN). The left internal thoracic artery was anastomosed to the LAD, the right internal thoracic artery was anastomosed to the first diagonal artery, and lengths of saphenous vein were anastomosed to the distal circumflex and right coronary arteries. There was some hemodynamic instability during the circumflex graft; if this graft had not been feasible a hybrid procedure would have been performed with percutaneous coronary angioplasty following the surgery. Following the construction of the proximal anastomoses Tisseel glue (Baxter AG, Vienna, Austria) was sprayed using the Duploject System (Immuno AG, Vienna, Austria) on both internal thoracic artery harvest beds and on all anastomoses, to further aid control of bleeding. It is not our normal policy to use hemostatic aids. The heparin was reversed and a further 2 pools of platelets administered. The patient was extubated at 3 hours postoperatively and the total drainage from the mediastinal drains was 425 mLs in 48 hours, no further platelet or blood transfusions were required.

Postoperatively his management was undertaken in close communication with the hepatologists and, apart from a minor chest infection, he made a smooth recovery with no evidence of hepatic decompensation. The patient was discharged home on the eighth postoperative day, and his liver transplant was performed 2-months later, from which he made a good recovery.

	Comment

Top Abstract Introduction Comment References

 
Liver cirrhosis poses particular problems for cardiac surgery with reported complication rates for Child class B (serum bilirubin 2.0–3.0 mg/dL, serum albumin 3.0–3.5 g/dL, controllable ascites, minimal neurologic disorder, good nutrition) cirrhotic patients undergoing cardiac surgery of 100% major morbidity and 80% mortality [1], with deaths due to postoperative infections and hemorrhagic complications leading to hepatic and multiorgan failure. Child class A cirrhotic patients have a quoted 25% risk of major complication, but may not have increased perioperatively complications [1]. Patients with advanced liver disease (Child B and C: serum bilirubin > 3.0 mg/dL, serum albumin < 3.0 g/dL, poorly controlled ascites, advanced coma, and nutrition poor) probably have an unacceptable risk for cardiac surgery. Bizouarn and associates [2] reported that the incidence of significant complications after cardiac surgery in patients with cirrhosis was high and that health status remained compromised even long after the surgery. Previous attempts to solve this problem have involved combined sequential CABG and OLT in cirrhotic patients including one with hepatocellular carcinoma [3], but this may not be a practical solution in patients with unstable angina requiring urgent CABG.

Progressive hepatic dysfunction is one of the most severe postoperative complications in the cirrhotic patient, and it is probably important to maintain stable and sufficient hepatic blood flow in the perioperative period to avoid further damage [4]. The use of cardiopulmonary bypass may not provide sufficient blood flow to the already compromised liver and by performing CABG surgery off-pump a more normal blood pressure and perfusion may reduce the risk of decompensation. A redo-CABG in a cirrhotic patient performed through a left thoracotomy without extracorporeal circulatory support has been described [5], but this involved a saphenous vein graft to the LAD and anastomosis to the descending thoracic aorta.

The presence of severe coronary artery disease in a patient who requires liver transplantation should not be considered as a contraindication to transplant, and with the advent of OPCAB and its future refinements the need for simultaneous CABG and OLT may not be necessary.

	References

Top Abstract Introduction Comment References

 

1. Klemperer JD, Wilson K, Krieger KH, et al. Cardiac operations in patients with cirrhosis. Ann Thorac Surg. 1998;65:85–87[Abstract/Free Full Text]
2. Bizouarn P, Ausseur A, Desseigne P, et al. Early and late outcome after elective cardiac surgery in patients with cirrhosis. Ann Thorac Surg. 1999;67:1334–1338[Abstract/Free Full Text]
3. Benedetti E, Massad MG, Chami Y, Wiley T, Layden TJ. Is the presence of surgically treatable coronary artery disease a contraindication to liver transplantation? Clin Transplant. 1999;13:59–61
4. Ninomiya M, Takamoto S, Kotsuka Y, Ohtsuka T. Indication and perioperative management for cardiac surgery in patients with liver cirrhosis. Jpn J Thorac Cardiovasc Surg. 2001;49:391–394[Medline]
5. Sakakibara Y, Imazuru T, Watanabe K, et al. Repeat coronary artery bypass in a patient with liver cirrhosis. Thorac Cardiovasc Surg. 1998;46:99–100[Medline]

This article has been cited by other articles:

				M. Pocar, D. Passolunghi, A. Moneta, and F. Donatelli Primary and redo valve replacement before and after liver transplantation Eur. J. Cardiothorac. Surg., October 1, 2007; 32(4): 674 - 675. [Abstract] [Full Text] [PDF]

				A. Ben Ari, E. Elinav, A. Elami, and I. Matot Off-pump coronary artery bypass grafting in a patient with Child class C liver cirrhosis awaiting liver transplantation Br. J. Anaesth., October 1, 2006; 97(4): 468 - 472. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Cornelia Carr Jatin Desai Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carr, C. Articles by Desai, J. Search for Related Content PubMed PubMed Citation Articles by Carr, C. Articles by Desai, J. Related Collections Minimally invasive surgery