Outcome of Open Heart Surgery in Patients with Liver Cirrhosis
Dr. Mohamed Ahmed Elawady, MD.
Lecturer of cardiothoracic surgery, Benha university
Back ground:
Open heart surgery in liver cirrhosis patients with is associated with significant increase
in perioperative morbidity and mortality.
Methods:
Prospective study to evaluate the outcome of elective open heart surgery in patients
with liver cirrhosis.
Results
Total 75 patients, 67 were A Child-Pugh and 8 patients were class B Child-Pugh. No
alcoholic or class C patients were included in the study. 59 patients were Hepatitis C
positive , 13 Hepatitis B positive and 3 patients were positive for both Hepatitis B and C.
67patients (89%) male, 8 female (11%), 23hypertensives and 18(24%)were diabetics.
Mean EF was 48.76±7.19.Mean CPB time was 59.28±20.31min and mean CX time
42.48±15.06min. Mean ventilation time was11.51± 8.62. Mean chest tube drainage
944.80±620.554 ml, minimal 190ml maximum 3500 ml .15 patients re-explored for
bleeding, (20%). Mean ICU stay was 67.68± 21.91hours. 16 patients (21.3%) had
wound infection, 11 had superficial and 4 had deep wound infection. The mean hospital
stay was 9.18±2.291days.Total morbidity was 55.33%, 49%in class A patients and
86.5% in class B patients. Four patients died with total mortality 5.3%, in class B
patients was 37.5% mortality and 1.49% in class A patients.
Conclusion:
Open heart surgery in liver cirrhosis patients carries high perioperative morbidity
especially postoperative bleeding and increase in incidence of infection with expected
high mortality.
1
2
INTRODUCTION
Egypt contains the highest prevalence of hepatitis C in the world. The national
prevalence rate of HCV antibody positivity has been estimated to be between 10-13%.
(1).
The estimated adjusted national prevalence rate of chronic hepatitis C infection is 7.8%
or 5.3 million people in 2004. Only one third of these individuals (1.75 million) are
estimated to have chronic liver disease and, among these one third (577,000 people)
are suffering from advanced liver disease (2). Consequently there is increase the
number of liver cirrhosis patients (LC) who have open heart surgery in Egypt.
The Child- Pugh classification has been widely used assess the severity of LC
classifying the patients into three classes: A, B, and C. A total score of 5-6 is considered
grade A (well-compensated disease); 7-9 is grade B (significant functional compromise);
and 10-15 is grade C (de-compensated disease). (3-4).
Liver cirrhosis been shown to be a major risk factor for cardiac surgery particularly when
using cardiopulmonary bypass as it increase both postoperative morbidity and mortality.
(5).
In cardiac surgery, liver cirrhosis increases perioperative morbidity and mortality for a
many reasons. First, vulnerability to bacterial infection is increased, which is related to
the severity of liver dysfunction, leading to abnormalities of the defense mechanisms.
Second, the liver plays an important role in the clotting process, and acute and chronic
liver diseases are commonly linked with coagulation disorders. Portal hypertension may
lead to congestive splenomegaly with trapping of platelets, leading to thrombocytopenia,
and these haemostatic disorders can cause postoperative bleeding (6-7).
PATIENTS AND METHODS
Prospective study in 75 liver cirrhosis patients who electively underwent open heart
surgery this study carried out in Al mahala cardiac center and Nasr city insurance
hospital. All patients had full clinical evaluation and full laboratory evaluation including
complete blood picture, complete liver function and complete renal functions test.
Enzyme-linked immunosorbent assay (ELISA) test was used in diagnose hepatitis
3
markers. Abdominal ultra sound is done for all patients to evaluate the liver condition
and diagnosis portal Hyperion. No liver biopsy was taken. Child Pugh classification
score is calculated for all patients. Table 1 shows the Child-Pugh Classification (3, 4).
Inclusion criteria:
1- Elective open heart surgery.
2-Good left ventricular function with ejection fraction above 35%.
Exclusion criteria are:
1- Emergency or urgent cases.
2- Redo open heart surgery.
3-Patients with poor left ventricular function with ejection fraction below 35%
4- Renal failure patients on regular dialysis.
All patients continue on their treatment until the morning of the surgery except antiplatelets, which are stopped for 7 days before surgery.
Midline sternotomy is used in all patients. All operations were performed utilizing
conventional cardiopulmonary bypass (CPB) giving cold antigrade crystalloid cardioplegic
solution repeated every 30 minutes. CPB was conducted using a membrane oxygenator
and mild hypothermia (35C).
The priming solution contained 1.5-2.Liters of lactated Ringer’s solution, mannitol,
heparin (2000 U/l).Before CPB was initiated heparin sodium was administered at an
initial dose of 300IU/kg. Additional heparin was administered if the celite-activated
clotting time became less than 400 seconds. The haematocrit was maintained between
20% and 25%. After weaning from CPB, heparin was neutralized with 10mg of
Protamine Sulphate for each 1,000 units of heparin.
Packed red blood cells were administered when haematocrit was less than 25%.fresh
frozen plasma and platelets were administered when platelet count was less than
40000/ml or as a part of control postoperative bleeding.
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Postoperative complications were classified as follow:
-Pulmonary: pneumonia, ventilator dependence more than 48 hours, pleural effusion
requiring an additional treatment or drainage.
- Infectious (wound infection either superficial or deep).
- Bleeding complications (re-exploration because of excessive mediastinal bleeding or
cardiac tamponade requiring drainage).
-Renal complications (increase in serum creatinine greater than 1.5mg/dl, oliguria (<0.5
ml/kg/min) for more than 6 hours postoperatively or any other indication for dialysis).
-Other postoperative complications related to liver diseases, such as encephalopathy,
hyperbilirubinemia and gastrointestinal bleeding as a result of varices were also
recorded.
Mortality is defined as death during a hospitalization for surgery, regardless of length of
stay, or within 30 days from hospital discharge.
All preoperative, operative and postoperative data including 3 months follow up after
discharge home are collected and analyzed.
RESULTS
During the study, 75 patients were eligible for the study.67 patients were A Child-Pugh
and 8 patients were class B Child-Pugh .No class C patients or alcoholic cirrhosis
included in the study. 59 patients were Hepatitis C and 13 Hepatitis B and 3 patients
were positive for both Hepatitis B and C virus.
Table (2) summarizes the preoperative demographic and laboratory results of the patients
The mean cardiopulmonary bypass time was 59.28±20.316min, the Cross-clamp time
42.48±15.06min. Tables (3&4) summarize all operative data.
Postoperatively no patients need IABP. No postoperative myocardial infarction. One
patient had delayed recovery and right sided hemiplegia, CT brain showed brain
hemorrhage.
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Postoperative mean 24 hour chest tube drainage was 944.80±620.55ml; minimal 190ml
maximum 3500 ml. 15 patients (20%) were re explored due to bleeding.
Regarding packed RBCS transfusion mean was 2.29±1.85units, fresh frozen plasma was
3.51±2.45units and platelets mean transfusion was 3.99±1.30units.
Mean Ventilation time was 11.51± 8.625hours. Mean ICU stay was 67.68± 21.91hours.
Twenty one patients (28%) had pleural effusion, all treated medically except 6 patients
needed repeated pleural taping. 16 patients (21.3%) had wound infection, 12 had
superficial and 4 patients readmitted due to deep wound infection, 2 of them had
rewiring. Mean hospital stay was 8.29±2.03days.Total morbidity was 55.3%, 49% in
class A patients and 87.5% in class B patients. Four patients died two due to bleeding
(re explored 3 times) and hepato-renal failure and the third due to sepsis, last one had
cerebral hemorrhage and sepsis. Three of those patients were Class B Child-Pugh
classification, so total mortality was 5.3%; in class B mortality was 37.5% patients and
1.75%in class A patients.
Table 5 shows the clinical outcome and postoperative laboratory results.
COMMENT
Limited experience suggests that cardiac surgery is associated with a high perioperative mortality rate in patients with cirrhosis. The high mortality rate occurs due to
major postoperative infections and bleeding rates rather than cardiac dysfunction. (8,9).
The high mortality is due to high risk of major postoperative infections and bleeding,
rather than cardiac dysfunction (9). Risk factors for hepatic de-compensation after
cardiac surgery include prolonged time of cardiopulmonary bypass, use of non pulsatile
cardiopulmonary bypass, and need for perioperative inotropic support. (9).
Bleeding is a common clinical problem in patients with liver disease. In most patients
with liver cirrhosis there are major alterations in the haemostatic pathways including
altered platelet and endothelial function, altered clotting factors and conditions such as
hyperfibrinolysis, dysfibrinogenemia. (6).In open heart surgery the situation is worse as
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the cardiopulmonary bypass alternates more the bleeding profile and the liver and
kidney functions.(9).
The postoperative high incidence of delayed wound healing and high infection rate is
expected in liver cirrhosis patients due to hypoalbumenia and relatively high incidence
of blood products transfusion. (10).
Most of the previous studies suggested that high incidence of high postoperative
complications after elective cardiac surgery leading to increase in the length of stay in
ICU and overall hospitalization time and expected high mortality rate. (11,12).
In our study we studied a relatively large number of patients (75 patients) with liver
cirrhosis, 67 of them patients were A Child-Pugh and 8 patients were class B ChildPugh with no class C and alcoholic patients. 15 patients re-explored for bleeding, (20%)
with mean chest tube drainage after operation 944.80±620.55 ml, minimal 190ml
maximum 3500 ml .These results confirmed the bleeding tendency in liver cirrhosis
patients after open heart surgery which also confirmed by other studies.(13, 14).
Total morbidity was 55.33%, 49%in class A patients and 86.5% in class B patients this
morbidity mainly due to bleeding tendency ,transfusion of blood products ,prolonged
ICU stay infection deterioration of liver function and pleural effusion rather than cardiac
causes. Four patients died with total mortality 5.3%, in class B patients was 37.5%
mortality and 1.49% in class A patients. Those results
differ from
the results of
Klemperer et al. (15) who reported 80% of postoperative mortality rate of in those with
Child's class B cirrhosis, but no mortality among those with Child's class A cirrhosis but
they studied only 13 patients and alcoholic cirrhosis patients were included.
Also Young et al (9) found the overall mortality rate was 25% in cirrhotic patients who
had open heart surgery, with 6% in class A, 67% in class B, and 100% in class C ChildPugh while Nobuhiko Hayashida, et al (16) reported 60%morbidty in patients with class
A cirrhosis and 100% of those with class B cirrhosis and class C cirrhosis.
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In another study Mohsen Hammad et al (17) reported 60% postoperative morbidity in
patients with Child-Pugh class A and 100% in patients with class B. Postoperative major
complications included progression of liver dysfunction, prolonged ventilation, infection,
renal failure and bleeding which nearly the same found in our study. They found overall
postoperative mortality rate of 23.8% with 6.3% in patients with class A and 80% in
class B patients. Most of the deaths were related to progression of liver dysfunction,
sepsis and multi-organ failure which again same cause of mortality of our patients.
When Amit Modi et al (18) reviewed all articles about the best evidence topic in
outcome of open heart surgery in cirrhotic patient they reported overall mortality of
17.1% and mean mortality for Child–Pugh class A, B and C was 5.2%, 35.4% and 70%,
respectively. Also the major morbidity ranged from 20 to 60% in Child-Pugh group A
and 50 to 100% in patients with class B and C.
But most of the previous studies were of low number of patients, including emergency
and alcoholic cirrhotic patients and class C patients which differ from our study in which
emergency cases were excluded and with no alcoholic and class C Child Pugh
classification patients and can explain the relatively low morbidity and mortality in our
study.
Conclusion
Patients with class A Child Pugh cirrhosis can tolerate open heart surgery procedures
with accepted mortality and morbidity especially postoperative bleeding and reexploration, however the risk of both morbidity and mortality in patients with Child Pugh
class B and is extremely high.
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References
1-Mohamed MK.: Epidemiology of HCV in Egypt 2004. The Afro-Arab Liver
Journal.2004; 3, No2, 41-52.
2- Abdel-Aziz F, Habib M, Mohamed MK et al.: Hepatitis C virus (HCV) infection in a
community in the Nile Delta: population description and HCV prevalence. Hepatology
2000; 32: 111–115.
3-Pugh RN, Murray Lyon IM, Dawson JL et al: Transection of the oesophagus for
bleeding oesophageal varices. Br J Surg. 1973 Aug; 60(8):646-9.
4- Lucey MR, Brown KA, Everson GT.et al. : Minimal criteria for placement of adults
on the liver transplant waiting list: a report of a national conference organized by the
American Society of Transplant Physicians and the American Association for the Study
of Liver Diseases. Liver Transpl Surg; 1997.3(6):628-37.
5- Lin CH, Lin FY, Wang SS, Yu HY, Hsu RB. : Cardiac surgery in patients with
cirrhosis. Ann Thorac Surg 2004; 79: 1551-4.
6- Thalheimer U, Triantos CK, Samonakis DN et al: Infection, coagulation, and
variceal bleeding in cirrhosis. Gut 2005; 54: 556-63.
7- Amitrano L, Guardascione MA, Brancaccio V.et al: Coagulation disorders in liver
disease. Semin Liver Dis; 2002: 22:83-96.
8- John D. Klemperer, Wilson Ko, Karl H. Krieger et al.: Cardiac operations in
patients with cirrhosis. Ann Thorac Surg, 1998; 65:85-87.
9- Yong An, Ying-Bin Xiao, Qian-Jin Zhong: Open-heart surgery in patients with liver
cirrhosis .Eur J Cardiothorac Surg 2007:3:1094-1098.
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10-Philippe Bizouarn, Antoine Ausseur, Pascal Desseigne et al: Early and late
outcome after elective cardiac surgery in patients with cirrhosis Ann Thorac Surg
1999:67; 1334-1338.
11- Farzan Filsoufi, Salzberg SP, Rahmanian PB et al.: Early and late outcome of
cardiac surgery in patients with liver cirrhosis. Liver Transpl: 2007 Jul; 13(7):990-5.
12- Cheng-Hsin Lin , Fang-Yue Lin , Shoei-Shen Wang et al: Cardiac Surgery in
Patients With Liver Cirrhosis The Annals of Thoracic Surgery:2005; 79, 5, 1551-1554.
13 - Akimasa Morisaki, Mitsuharu Hosono, Yasuyuki Sasaki et al. :Risk factor
analysis in patients with liver cirrhosis undergoing cardiovascular operations. Ann
Thorac Surg 2010; 89:811–817.
14-Takashi Murashita, Tatsuhiko Komiya, Nobushige Tamura et al: Preoperative
evaluation of patients with liver cirrhosis undergoing open heart surgery. Gen Thorac
Cardiovasc Surg. 2009 Jun; 57(6):293-7.
15- John D. Klemperer, Wilson Ko, Karl H. Krieger et al.: Cardiac operations in
patients with cirrhosis Ann Thorac Surg 1998; 65:85-87.
16- Nobuhiko Hayashida, Takahiro Shoujima, Hideki Teshima et al.: Clinical
outcome after cardiac operations in patients with cirrhosis: Ann Thorac Surg 2004;
77:500-505.
17- Mohsen Hammad, Asem Elfert, Hasan Elbatea et al: clinical Outcome after
Cardiac Operations Using Cardiopulmonary Bypass in Patients with Liver Dysfunction
Arab J Gastroenterol 2006; 7(3): 98-101.
18- Amit Modi, Hunaid A. Vohra, Clifford W. Barlow: Does patients with liver
cirrhosis undergoing cardiac surgery have acceptable outcomes? Interactive
CardioVascular and Thoracic Surgery 11 (2010) 630–634.
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Table 1: Child-Pugh Classification of Severity of Liver Disease.A total score of 5-6 is
considered grade A (well-compensated disease); 7-9 is grade B (significant functional
compromise); and 10-15 is grade C (de-compensated disease).
Parameter
Points assigned
1
2
3
Absent
Slight
Moderate
Bilirubin, mg/dL
</= 2
2-3
>3
Albumin, g/dL
>3.5
2.8-3.5
<2.8
4-6
>6
1.8-2.3
>2.3
Ascites
Prothrombin time
Seconds over
1-3
control
<1.8
INR
Encephalopathy
None
Grade 1- Grade 3-4
2
Table (2): Preoperative Demographic and Laboratory Results.
Variable
Result
Age
53.22± 8.23
Male
67(89%)
Female
8 (11%)
Hypertensive
23(31%)
EF
48.76±7.19
Diabetics
18(24%)
Creatinine
0.81 ± 0.18
Class A
67(89.3%)
Class B
8(10.66)
Hepatitis C +ve
59(78.66%)
Hepatitis B +ve
13(17.33%)
Hepatitis B&C +ve
3(4%)
11
Urea
18.13± 6.80
Bilirubin
0.90± 0.28
AST
34.02± 15.87
ALT
29.76± 13.83
Albumin
3.96± 0.36
HB
12.78 ± 1.40
Platelets
168.40±55.65
Table (3): Surgical Procedures.
AVR: aortic valve replacement, CABG: Coronary artery bypass surgery, MVR: mitral
valve replacement, ASD atrial septal defect closure, DVR double valve replacement.
PROCEDURE Number of
Patients
AVR
11
CABG
45
MVR
14
ASD Closure
3
DVR
2
Table (4): Operative Data. (CPB Cardiopulmonary Bypass Time, Xct (Cross Clamp
Time).
Variable
Result
CPB(min)
59.28±20.31min
CXT(min)
42.48±15.06min
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Table (5): Clinical Outcome and Postoperative Laboratory Results.
Variable
Result
VENTILATION TIME(HOURS)
11.51± 8.62
ICU TIME (HOURS)
67.68± 21.91
Blood Loss ML
944.80±620.55
Re-exploration
15(20%)
PRBCS Transfusion(unit)
2.29±1.85
FFP(unit)
3.51±2.45
PLALETS Transfusion (unit)
3.99±1.30
HOSPITAL STAY(DAYS)
8.29±2.03
Total Morbidity
55.3.2%,
Morbidity in class A
49%
Morbidity in class B
86.5%
Total mortality
5.3%
Mortality in Class A
1.49%
Mortality in Class B
37.5%
ALT
76.56± 45.01
AST
67.36± 16.18
BILIRUBIN
1. 73± 0.59
PT
29.02± 10.19
PTT
48.57±20.10
INR
1.79± 0.42
CREATININE
1.12± 0.64
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