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Ann Thorac Surg 2005;79:1551-1554
© 2005 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Cardiac Surgery in Patients With Liver Cirrhosis

Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan, China

Accepted for publication November 10, 2004.

^_* Address reprint requests to Dr Hsu, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd, Taipei, Taiwan 100, ROC (E-mail: ronbin{at}ha.mc.ntu.edu.tw).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Cardiac surgery was infrequently performed in patients with liver cirrhosis, and its clinical outcome has been reported only in small series. We sought to evaluate the clinical outcome of cardiac operation in patients with noncardiac liver cirrhosis.

METHODS: Data were collected by a retrospective case note review. The preoperative, intraoperative, and postoperative variables were recorded. The severity of liver cirrhosis was graded using the Child-Pugh classification.

RESULTS: Between January 1993 and May 2004, 18 patients with liver cirrhosis underwent cardiac surgery at the authors' hospital. Thirteen patients had hepatitis virus infection, and 5 cases were alcohol related. Thirteen patients were classified as Child A cirrhosis, 4 were class B, and 1 was class C. Sixteen patients underwent cardiac surgery with the use of cardiopulmonary bypass, and 2 patients underwent off-pump coronary artery bypass surgery. The overall in-hospital mortality rate was 6% (1 of 18), and there was no death in 5 class B and C cirrhotic patients. The rate of major complication was 39% in class A and 80% in class B and C.

CONCLUSIONS: Although the postoperative complication was common, cardiac operation could be performed safely in patients with mild and advanced liver cirrhosis.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Cardiac surgery was infrequently performed in patients with liver cirrhosis, and its clinical outcome was reported only in small series [1–4]. The reported in-hospital mortality rate in cirrhotic patients of Child class B and C was high [1–3]. Cardiac surgery with the use of cardiopulmonary bypass was not recommended for patients with advanced liver cirrhosis. Hepatitis virus infection and liver cirrhosis are prevalent in our country. Here, we sought to evaluate the clinical outcome of cardiac operation in patients with noncardiac liver cirrhosis.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients
Information was collected retrospectively on all patients with liver cirrhosis who underwent cardiac surgery between January 1993 and May 2004. Data on age, sex, medical comorbidities, surgical procedure, and clinical outcome were recorded. The diagnosis of liver cirrhosis was based on clinical history and physical stigmata consistent with cirrhosis, and findings of abdominal sonography. The diagnosis of liver cirrhosis was based on ultrasonic findings, which was characterized by a coarsened heterogeneous echo pattern, increased parenchymal echogenicity, and nodularity of the liver surface [5–7]. No patients received liver biopsy to confirm the diagnosis of liver cirrhosis. The severity of cirrhosis was graded according to the Child-Pugh classification [8].

Cardiac Surgery
All of the procedures of conventional coronary artery bypass grafting and valve surgery were performed through a median sternotomy. Cardiopulmonary bypass was instituted with an ascending aortic and separate caval venous cannulation. Before bypass was started, heparin sodium was administered at an initial dose of 300 IU/kg. Additional heparin was administered if the activated clotting time became less than 500s. During cardiopulmonary bypass, the hematocrit was maintained between 18% and 25%, perfusion flow between 2.4 and 2.8 L · min^–1 · m^–2, mean arterial pressure between 50 and 70 mm Hg, and systemic temperature between 28° and 32°C. After the surgical procedure, heparin was neutralized by continuous intravenous administration of protamine sulfate during a 5-minute period.

Beginning from June 2000, patients with coronary artery disease were treated with coronary artery bypass grafting without the use of cardiopulmonary bypass or off-pump coronary artery bypass grafting. The operation was also performed through a median sternotomy. The heparin dose is two thirds of the standard dose for cardiopulmonary bypass. It is administered before division of the internal mammary artery. The target activated clotting time is longer than 300 seconds. This is partially reversed with one half the calculated protamine dose after the completion of coronary anastomosis.

Postoperative management in intensive care unit was the same as that in routine patients receiving cardiac surgery. Blood components were given whenever needed, and no aprotinin was used in our patients. Major complications were classified as neurologic (consciousness disturbance, seizure, or stroke), pulmonary (prolonged ventilator support for more than 48 hours), infectious (wound infection, bacteremia, pneumonia, or urinary tract infection), gastrointestinal, renal (acute renal failure or need for new dialysis), bleeding (profuse chest tube drainage in need of reoperation), and hepatic decompensation (hepatic function deterioration or hepatic failure).

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Patient Characteristics
Eighteen patients were identified. There were 14 men and 4 women, and the median age was 56 years (range, 35 to 76). The causes of liver cirrhosis were hepatitis virus infection in 13 patients and alcoholic in 5 patients. The severity of liver cirrhosis was Child class A in 13 patients, Child class B in 4 patients, and Child class C in 1 patient. Patient demographics and comorbid conditions were listed in Table 1. The diagnosis of heart disease was infective endocarditis in 8 patients, rheumatic heart disease in 4 patients, coronary artery disease in 4 patients, and degenerative valvular disease in 2 patients. The comorbid medical diseases were diabetes mellitus in 7 patients, hypertension in 5 patients, hepatocellular carcinoma in 2 patients, and intravenous drug abuse in 1 patient. The median level of serum total bilirubin was 1.0 mg/dL (range, 0.3 to 5.2 mg/dL); serum albumin, 3.3 mg/dL (range, 2.4 to 4.5 mg/dL); and platelet count, 116 K/µL (range, 44 to 366 K/µL).

The median duration of intensive care unit stay and hospital stay were 2 days (range, 1 to 44) and 15 days (range, 7 to 85), respectively. Major complications occurred in 9 patients: profuse postoperative bleeding in 4 patients, hepatic decompensation in 2 patients, and infection in 4 patients (deep sternal wound infection in 2, bacteremia in 1, and lumbar diskitis in 1). The rate of major complication was 39% in patients of Child class A cirrhosis and 80% in class B and C.

Two patients were lost after discharge. The median duration of follow-up was 24 months (range, 3 to 101). Two patients had late death. One was a 51-year-old woman with Child A cirrhosis, who had preoperative diagnosis of hepatocellular carcinoma and undertook aortic valve replacement. The postoperative course was smooth, but she died of complications of the malignancy 6 months after the procedure. The other was a 35-year-old man with Child B cirrhosis, who underwent aortic and mitral valve surgery for infective endocarditis. He had sudden death 12 months after operation.

Advanced Liver Cirrhosis
Five patients with advanced liver cirrhosis (Child class B or C) underwent cardiac surgery because of infective endocarditis. There was no in-hospital death, but 4 of 5 patients suffered major postoperative complications (Table 2). Three patients had profuse postoperative bleeding, and 1 patient had bacteremia after the operation.

The only patient with Child class C liver cirrhosis was a 49-year-old man with alcoholic liver disease. He had marked hyperbilirubinemia, hypoalbuminemia, and bleeding tendency before the operation. He underwent aortic and mitral valve replacement for infective endocarditis. He had a stormy postoperative course of profuse bleeding, hepatic decompensation, gastrointestinal bleeding, deep sternal wound infection, and systemic fungal infection. He was discharged after a stay in the intensive care unit of 44 days and a hospital stay of 85 days. One patient was a 35-year-old man with Child class B alcoholic liver cirrhosis who underwent aortic and mitral valve replacement for infective endocarditis; he had profuse bleeding and recovered smoothly after reoperation. One patient was a 58-year-old man with hepatitis B virus-related cirrhosis who underwent mitral valve replacement for infective endocarditis; he had persistent fever and bacteremia and was discharged after a prolonged course of intravenous antibiotic treatment.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
The clinical outcome of cardiac surgery in patients with liver cirrhosis has been reported infrequently. Previous reports were limited by small case number [1–4, 9–12]. Patients with minimal clinical evidence of liver cirrhosis can tolerate cardiopulmonary bypass and cardiac surgical procedures. However, major complication developed in 89% to 100% of patients with more advanced liver cirrhosis, and the in-hospital mortality rate was as high as 50% to 100%. It was recommended that patients with advanced liver cirrhosis not be offered cardiac surgery [1]. In our study, the in-hospital mortality rate was 8% for patients with Child class A liver cirrhosis. The only death occurred in the early year of this study, and there has been no hospital death since 1995. In addition, 5 patients with Child class B and C liver cirrhosis tolerated cardiac surgery using cardiopulmonary bypass. Although the rate of major complication rate was 80%, there was no in-hospital mortality. It was unclear whether we had a lower mortality rate among patients with advanced liver cirrhosis [1–4]. It was possible that our patients were operated on on an emergency basis because of infective endocarditis. Infective endocarditis complicating cirrhosis has been reported infrequently, and the clinical outcome was poor [13–17]. Severe infection may aggravate the clinical condition of cirrhotic patients, and hepatic decompensation could develop after infective endocarditis in patients with mild liver cirrhosis [16]. Antibiotic therapy for infective endocarditis may also worsen hepatic function. These deteriorations in clinical condition and blood biochemistry tests are generally transient. Once the source of infection was surgically removed, the exacerbated liver function returned to its baseline. An improved clinical outcome could be achieved in those patients with advanced liver cirrhosis because of infective endocarditis. In addition, our series of patients with Child-Pugh classes B and C are relatively young in age. Because a patient's age may influence postoperative clinical results, the improved results of this study may be associated with younger age.

Comparing patients in prior studies [1–4] and ours, there were no differences in age, sex, severity of liver cirrhosis, serum bilirubin, and serum albumin. The only difference was the cause of liver cirrhosis. The causes of liver cirrhosis were hepatitis virus infection in the majority of our cases. A similar percentage was seen in the study by Hayashida and associates [4]. However, alcoholic liver cirrhosis predominated in other reports [1–3], and it made up 50% to 77% of their cases. The in-hospital mortality rate was 17% in the study by Hayashida and colleagues [4], whereas the mortality rate was 25% to 31% in other reports [1–3]. Whether the cause of liver cirrhosis influences the outcome of cardiac surgery needs further investigation.

This study was limited by small case number and retrospective study. However, this study is one of the largest series of cardiac surgery and liver cirrhosis ever reported in the literature. And this study is also the first to demonstrate the feasibility of cardiac surgery in patients with advanced liver cirrhosis.

In conclusion, although postoperative complication was common, cardiac operation could be performed safely in patients with mild and advanced liver cirrhosis.

	References

Top Abstract Introduction Patients and Methods Results Comment 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): Cheng-Hsin Lin Hsi-Yu Yu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lin, C.-H. Articles by Hsu, R.-B. Search for Related Content PubMed PubMed Citation Articles by Lin, C.-H. Articles by Hsu, R.-B. Related Collections Cardiac - other