Liver Cirrhosis in Cardiac Surgery: Dangerous but Elusive

Background: Patients with liver cirrhosis are considered as high risk for cardiac surgery because of complications and mortality. The purpose of this study was to investigate the risk characteristics for mortality of cardiac surgery patients with liver cirrhosis.

Method: Data were collected from 287 patients with liver cirrhosis in our cardiac surgery department. Thereof, 218 patients underwent cardiac surgery. Baseline, comorbidities, preoperative routine diagnostics, intraoperative and postoperative course as well as detailed diagnostic data of liver cirrhosis were collected retrospectively.

Results: Overall, 28% of the surgery patients died. Of 146 patients in CHILD class A, 8.9% died, of 51 in CHILD class B, 52.9% died and of 21 in CHILD class C, 100% died. The nonsurvivors showed a significantly lower prothrombin time (70 vs. 80%, p = 0.013) and significantly higher total bilirubin (25.6 vs. 18.7 µmol/L, p = 0.005) and CRP levels (52 vs. 20 mg/L, p < 0.001) immediately preoperatively. Furthermore, we observed in nonsurvivors a significantly increased cholinesterase (86 vs. 43 µkat/L) and ammonia level (83 vs. 56 µmol/L) as well as lower albumin (28 vs. 32 g/L). The nonsurvivors showed significantly more encephalopathy (14.8 vs. 5.1%, p = 0.035, OR: 3.2) and pulmonary hypertension (31.1 vs. 15.3%, p = 0.014, OR: 2.5) preoperatively. Furthermore, the presence of the following clinical findings appeared to increase the risk of mortality: ascites (OR: 1.9), icterus (OR: 2.6), hepatorenal syndrome (OR: 2.2), spider navi (OR: 7.8), and caput medusae (OR: 7.8). LVEF, TAPSE, gender distribution, comorbidities such as chronic renal failure and dialysis dependency, COPD, peripheral artery disease, diabetes mellitus, and proportion of combination procedures were very similar between survivors and nonsurvivors. The nonsurvivors were on average 2 years older and had significantly longer x-clamping and cardiopulmonary bypass time (p = 0.011, p < 0.001).

Conclusion: Although most clinical findings and laboratory parameters appearing in advanced stages of cirrhosis cannot be treated, some of them can at least be ameliorated preoperatively. However, cardiac surgery should be restrictively indicated in advanced stages of liver cirrhosis and almost entirely avoided in patients with CHILD C, i.e., performed only in thoroughly selected cases. Duration of surgery should be kept as short as possible, thus advocating experienced surgeons only for such procedures.

Publication History

Article published online:
03 February 2022