Do patients with liver cirrhosis undergoing cardiac surgery have acceptable outcomes?☆

Amit Modi 0 Hunaid A. Vohra 0 Clifford W. Barlow 0 0 Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust , Tremona Road, Southampton SO16 6YD, UK A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with liver cirrhosis have acceptable outcomes after undergoing cardiac surgery. Altogether 97 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. One prospective and another eight retrospective studies involving adult population of patients with liver cirrhosis undergoing various cardiac surgical procedures were selected. In these studies, the overall mortality was 17.1% and combined mean mortality for Child-Pugh class A, B and C was 5.2%, 35.4% and 70%, respectively. The major morbidity ranged from 20 to 60% in group A and 50 to 100% in the patients with more advanced hepatic disease. Some studies have demonstrated that thrombocytopenia, decreased serum cholinesterase and high preoperative total bilirubin levels are significantly associated with worse clinical outcomes. These studies, although with small samples, collectively demonstrate that patients with Child-Pugh class A cirrhosis tolerated cardiac surgical procedures with a mild increase in mortality and morbidity. However, the risk of mortality in patients with Child-Pugh class B and C or MELD score )13 is extremely high. Nevertheless, even if these patients underwent successful surgery, their long-term survival was significantly poorer and their health status remains compromised even well after cardiac surgery because of persistent liver dysfunction. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction A best evidence topic was constructed according to a structured protocol. This protocol is fully described in ICVTS w1x. 2. Clinical scenario A 66-year-old man with alcohol-related liver cirrhosis presents with dyspnoea (NYHA II). Echocardiogram demonstrated severe mitral regurgitation due to posterior mitral leaflet prolapse, good left ventricular systolic function and increased pulmonary artery pressures. Coronary angiogram is pending your decision-making in favour of surgery. You routinely use EuroSCORE to risk stratify but this does not account for liver cirrhosis. Therefore, you resolve to search the literature to find the best evidence. 3. Three-part question Do wpatients with liver cirrhosisx, undergoing wcardiac surgeryx have acceptable wclinical outcomesx? Details of ChildPugh Classification and MELD score are available from the author upon request. *Corresponding author. Tel.: q44 2380 777222; fax: q44 2380 798508. E-mail address: (C.W. Barlow). 2010 Published by European Association for Cardio-Thoracic Surgery 4. Search strategy Medline 1950 to March 2010 using the OVID interface. wexp Thoracic SurgeryyOR heart surgery.mp. OR valve surgery.mp. OR exp Coronary Artery BypassyOR cardiac surgery.mp.x AND wliver dysfunction.mp. or exp Liver DiseasesyOR Cirrhosis.mp.x 5. Search outcome Four hundred and forty papers were found, of which nine were included in the BET analysis reported below. The relevant papers are presented in Table 1. 6. Comments Nine clinical studies, one prospective and eight retrospective, involving 210 adult patients were found to be suitable. The studies looked at the clinical outcomes of patients with liver cirrhosis undergoing a wide range of cardiac surgical procedures. An et al. w2x studied 24 patients with liver cirrhosis who underwent cardiac surgery to evaluate morbidity, mortality and predictors of outcome. Patients were divided into three groups based on ChildPugh classification (CPC). They observed that 53% patients with class A cirrhosis and 100% with class B and C cirrhosis suffered postoperative compliRetrospective study (level 2b) Murashita et al., (2009), Gen Thorac Cardiovasc Surg, Japan, w3x Retrospective study (level 2b) Retrospective study (level 2b) Retrospective study (level 2b) Patient group 24 patients with liver cirrhosis underwent cardiac surgery May 1996June 2005 ChildPugh As17 ChildPugh Bs6 ChildPugh Cs1 Mean ages53"13 years M:Fs10:14 12 patients with liver cirrhosis underwent cardiac surgery January 2002December 2006 ChildPugh As6 ChildPugh Bs6 27 patients with liver cirrhosis underwent cardiac surgery January 1998December 2004 ChildPugh As10 ChildPugh Bs11 ChildPugh Cs6 Mean ages58"10 years M:Fs20:7 With CPBs22 Without CPBs5 42 patients with liver cirrhosis underwent cardiac surgery January 1991January 2009 Major morbidity ChildPugh A ChildPugh B ChildPugh C Mean ventilation time Mean ITU stay Re-opening rates ChildPugh A ChildPugh B Major morbidity ChildPugh A ChildPugh B Major morbidity ChildPugh A ChildPugh B ChildPugh C Re-opening rates ChildPugh A One-year survival ChildPugh A ChildPugh B ChildPugh C 32"22 hours 11"8 days High preoperative serum bilirubin Low preoperative serum cholinesterase Prolonged CPB time Thrombocytopenia low preoperative serum cholinesterase Mortality worse with increasing ChildPugh class and preoperative thrombocytopenia Unintentional statistical bias possible Mortality and morbidity not linked to the aetiology of cirrhosis Inherent biases Relatively small sample Surprisingly, mortality is lower in stage B, although morbidity is higher Operative mortality not significantly correlated with MELD scores No mortality observed in OPCAB patients Perioperative deaths excluded from Kaplan Meier survival analysis (Continued on next page) Suman et al., (2004), Clin Gastroenterol Hepatol, USA, w6x Retrospective study (level 2b) Lin et al., (2005), Ann Thorac Surg, China, w7x Retrospective study (level 2b) Retrospective study (level 2b) Patient group ChildPugh As30 ChildPugh Bs12 Mean ages69"8.5 years M:Fs31:11 Postoperative Morbidity: ns13 No morbidity: ns29 Mean MELD scores11.8"6 44 patients with liver cirrhosis underwent on-pump cardiac surgery January 1992June 2002 Analysed for any relationship of child classyscore and MELD score for postoperative hepatic decompensation and death ChildPugh As31 ChildPugh Bs12 ChildPugh Cs1 18 patients with liver cirrhosis underwent cardiac surgery January 1993May 2004 ChildPugh As13 ChildPugh Bs4 ChildPugh Cs1 Median ages56 years (3576 years) M:Fs14:4 With CPBs16 Without CPBs2 13 patients with liver cirrhosis underwent cardiac surgery ChildPugh As8 ChildPugh Bs5 Mean ages65"8.3 years M:Fs11:2 Median survival Morbidity group (M) No morbidity group (N) CP score )7 Major morbidity ChildPugh A ChildPugh B ChildPugh C Median ITU stay Re-opening rates ChildPugh A ChildPugh B 31"26.6 months 35.7"19.8 months (Ps0.3146) Significant morbidity with MELD )13 86% sensitivity and 92% specificity for mortality 2 (144) days 15 (785) days Relat (...truncated)