Title: Outcome of Elective Coronary Revascularization in Patients with Liver Cirrhosis
Authors: Dr. Mohamed Ahmed El Awady, MD., Dr. Moatz Rezk, MD.
Institutions: Cardiothoracic Surgery Department, Banha Medical School, Banha University,
Egypt.
Keywords: Liver, Cirrhosis, CABG.
Word Count: 2327
Corresponding Author: Dr. Mohamed Ahmed El Awady
Address: SBCC, Po Box11850 DAMMAM, SAUDI ARABIA.
Telephone: +9660599276628
Fax: +9660381555685
E-mail: mohamedawady@yahoo.com
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Outcome of Elective Coronary Revascularization in Patients with Liver Cirrhosis
Dr. Mohamed Ahmed El Awady, MD., Dr. Moatz Rezk, MD
Objectives:
Coronary artery bypass grafting in cirrhotic patients carries high risk of morbidity and
mortality. Most of these complications are related to hepato-renal failure, bleeding and
postoperative wound infection rather than cardiac problems.
Methods:
Prospective study to evaluate elective CABG early postoperative outcome of elective CABG
in patients with Class A Child Pugh liver cirrhosis.
Results
From October 2007 to April 2011total 59 patients with Class A liver failure underwent
elective CABG.37male, 22female.42hypertensives and 28diabetics.Mean1st 24hours chest
tube drainage was 853.80±56.10ml, minimal 130ml maximum 3500 ml.12 patients (20.3%)
were re-explored for bleeding. Mean ventilation time was 10.48± 6.65 hours. Mean ICU stay
was 59.52± 13.91hours. Two patients (3.38%) died one patient due to hepato-renal failure (re
explored 3 times) while the 2nd patient died after delayed recovery due to cerebral hemorrhage
. 20 patients (33.89%) had wound infection ,two need debridement and rewiring . Mean
hospital stay was 9.18±2.29days. Total morbidity was 49%. Total mortality was 3.38%.
Conclusion:
Elective CABG can be tolerated satisfactorily in class A Child Pugh cirrhotic patients with
high incidence of the postoperative complications specially bleeding and wound infection.
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INTRODUCTION
Open heart surgery in cirrhotic patients had relatively high risk of morbidity and mortality
when compared to non cirrhotic patients mainly Postoperative liver decomposition, bleeding
and high incidence of postoperative wound infection (1-5)
Child Pugh classification (6) (Table 1) consists of certain clinical, laboratory and radiological
parameters to classify liver cirrhotic patients into A, B and C classes. Class A has the best
condition while class C has the worst condition.
Table 1: Child-Pugh Classification of Severity of Liver Disease (6).
Parameter
Points assigned
1
2
3
Ascites
Absent
Slight
Moderate
Bilirrubin, mg/dL
</= 2
2-3
>3
Albumin, g/dL
>3.5
2.8-3.5
<2.8
Seconds over control
1-3
4-6
>6
INR
<1.8
1.8-2.3
>2.3
Encephalopathy
None
Grade 1-2 Grade 3-4
Prothrombin time
INR: International Normalised Ratio. A total score of 5-6 is considered grade A (wellcompensated disease); 7-9 is grade B (significant functional compromise); and 10-15 is grade
C (de-compensated disease).
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Model for End-Stage Liver Disease (MELD) score (7) are calculated in cirrhotic patients to
help in prediction of the excepted morbidity and mortality. MELD score ranging from 6 to 40,
patients with score of 6 are the best ill patients while patients of 40 are the sickest one.
The expected morbidity and mortality is much higher in patients with advanced Child Pugh
Classification and high MELD score but there is no accurate predicator of outcome of open
heart surgery in liver cirrhosis patients. Some studies used Child Pugh Classification others
used Model for End-Stage Liver Disease (MELD) score to evaluate the outcome of CABG in
liver cirrhosis patients but most of these studies of had limited number of patients (4, 5).
The number of cirrhotic patients undergoing CABG is increasing in Egypt as it has one of the
highest percentages of hepatitis C patients in the world ranging from 10% to 13% of the
population (8), most of these patients are class A Child Pugh classification so we had this
prospective study to evaluate the outcome of CABG in A class Child Pugh patients. All
preoperative, operative and postoperative details are collected and analyzed.
PATIENTS AND METHODS
From April 2008 to April 2011 A prospective study to evaluate the outcome of elective
CABG in class A cirrhotic patients. 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 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
and MELD score are calculated for all patients.
Inclusion criteria:
1- Elective CABG.
2-Class A Child Pugh.
3-Good left ventricular function with ejection fraction above 35%.
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Exclusion criteria are:
1- Class B and C Child Pugh classification.
2- Emergency or urgent CABG.
3- Redo CABG.
4- Open heart surgeries rather than CABG like valve surgery or combined surgery like
CABG+ valve surgery.
5-Patients with poor left ventricular function with ejection fraction below 35%
6- Renal failure patients on regular dialysis.
All preoperative, operative and postoperative data including 3 months follow up after
discharge home are collected and analyzed.
All patients continue on same drugs they usually use until the morning of the surgery except
anti-platelets, which are stopped for 7 days before surgery.
After the patients are anesthetizes, midline sternotomy is done. Pedicled left anterior
mammary artery (LIMA) is harvested 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).
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.
Postoperative complications were classified as follow:
-Pulmonary: pneumonia, ventilator dependence greater than 48 hours, excessive pleural
effusion requiring an additional drainage.
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- Infectious (superficial and deep sternal wound infection).
- 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.
Values of continuous variables were expressed as mean and standard deviation performed
with computerized statistical packages (SPSS 18.0 software, SPSS, Chicago, IL, USA).
RESULTS
Total 59 patients were eligible for the study. Main cause of liver cirrhosis was hepatitis C (42
patients) and Hepatitis B (17patients) with no Alcoholic cirrhosis.47 male and 12 female .28
patients were diabetics while 42 were hypertensives. Mean MELD score was15.2±3.38
(minimal 8, maximum 23). Table 2 summarizes the preoperative patient’s profile.
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Table (2): Preoperative Demographic and Laboratory Results.
Variable
Mean& Percent
AGE
53.22± 8.23
MALE
37(62.71%)
FEMALE
22 (37.28%)
HYPERTENSIVE 12(16%)
EF
52.76±6.79
DIABETICS
28(47.45%)
MELD score
15.2±3.38(8-23)
CREATININE
1.03 ± 0.18
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
PLATLETS
168.40±55.65
EF: ejection fraction; HB: hemoglobin; ALT: Alanine Aminotransferase; AST: Aspartate
Aminotransferase.
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Mean number of grafts was 2.72 ±0.57. Mean cardiopulmonary bypass time was 62.27±6.40
minutes (minimum45, maximum78). Mean Cross-clamp time it was 41.53±5.85 (minimum 28
maximum 55min). No patients need intra aortic balloon pump. Table 3 summarizes the
operative data.
Table (3): Operative Data of the Patients.
Variant
Mean &ST
GRAFTS
2.72±0.57(Min2,Max4 grafts)
CPB(min)
CXT(min)
53.28±20.31min
38.14±16.08min
CPB: cardio-pulmonary bypass, CXT: cross clamp time, Min: minute. Min: minimum
Max: maximum.
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The postoperative mean chest tube drainage was 853.80±56.10ml; minimal 130ml maximum
3500 ml. Mean packed RBCS transfusion was 2.18±1.68 units. Mean fresh frozen plasma
(FFP) Transfusion was 3.64±2.48 units. Mean platelets transfusion was 3.99±1.30 units. No
postoperative myocardial infarction diagnosed by ECG and repeated cardiac enzyme. 12
patients were re-explored for bleeding (20.3%), 8 of them had cardiac tamponade. Mean
ventilation time was 10.48± 6.6. Mean ICU stay was 59.52± 13.91hours.20 patients (33.89%)
had wound infection,15 of them had leg wound infection,2 patients with mediastinitis needed
debridement and rewiring. one patient had left sided clotted haemothorax diagnosed by CT
chest drained though left mini thoracotomy. 21 patients(35.59%) had left pleural effusion ,all
treated medically except 6 patents needed repeated pleural taping. Four patients readmitted
due to mediastinitis, 2 of them had rewiring. Mean Hospital stay was 9.18±2.29days.Total
morbidity was 49%. Total mortality was 3.38%. (2 patients),1st was re-explored 3 times for
bleeding and died due to hepato-renal failure, 2nd patient had delayed recovery with right
sided hemiplegia .CT brain showed cerebral hemorrhage. Table 4 summerizes the
postoperative outcome. Table (4): Postoperative Outcome and Laboratory Results.
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Variable
VENTILATION TIME
ICU TIME
HOSPITAL STAY
BLOOD LOSS
RE-XPLORATION
Tamponade
PRBCS TRANSFUSION
(unit)
FFP(unit)
PLALETS
TRANSFUSION(unit)
DEATH
ALT
AST
TB
UREA
CREATININE
Mean& SD
10.48± 6.65
59.52± 13.91
9.18±2.29
853.80±56.10
12(20.3%),
8(13.55%)
2.18±1.68
3.64±2.48
3.99±1.30
2(3.38%)
64.56± 45.01
42.38± 16.18
0.98± 0.52
18.90± 6.93
1.05± 0.43
SD: standard deviation; TB: total bilirubin; ALT: Alanine Aminotransferase; AST: Aspartate
Aminotransferase; ICU: intensive care Unit; FFP: fresh frozen Plasma; PRBCS: packed red
blood cells.
Discussion
Open heart surgery in cirrhotic patients carries high risk of postoperative morbidity and
mortality. (1-5). There is Limited experience in open heart surgery in class A cirrhotic
patients and most of these studies are of limited number (3,10-12) , emergency cases are
included(13)or wide variety of surgical procedure are included(6).The total morbidity of open
heart surgery in class A cirrhotic patients ranging from 39% to 60 % (13 -17). Most of these
complications are not related to cardiac complications and mostly related to hepato-renal
failure, bleeding and high incidence of postoperative infection (1-5, 8, 9). There is no accurate
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predicator of outcome of CABG surgery in those patients as some studies used Child Pugh
classification while others used MELD score as prognostic values for open heart surgery in
cirrhotic patients (18, 19).
Bleeding is major clinical problem of CABG in patients with liver disease as there are major
alterations in the haemostatic pathways in most patients with liver disease including altered
platelet and endothelial function, altered clotting factors and conditions such as
hyperfibrinolysis, dysfibrinogenemia and renal failure which may be superimposed on these
underlying abnormalities (20). Also Cardiopulmonary Bypass machine aggravates the
coagulopathy inducing platelet dysfunction, fibrinolysis, and hypocalcemia (21).
The postoperative high incidence of delayed wound healing and high infection rate is
expected in this group of patients due to hypoalbumenia and relatively high incidence of
blood products transfusion. (20).
In our study the total morbidly percent was 49% most of these complications are related
mainly to bleeding, infection, liver de-compensation and renal impairment rather than low
cardiac output. In our study elective CABG in class A cirrhosis while other studies with
relatively high morbidity emergency cases are included and other cardiac operations rather
than CABG (3, 12-15).
The mortality of open heart surgery in liver cirrhotic class A patients differs from study to
other ranging from 5.2 % (2) to 15% (13).mostly related to sepsis and hepato-renal failure. In
our study as emergency cases and other procedure rather than elective CABG are exclude, the
postoperative mortality in was 3.38% mainly due to hepto-renal failure and cerebral
hemorrhage. Table (4) summarizes the postoperative outcome and laboratory results.
Conclusion:
Elective Coronary artery bypass surgery in patients with class A Child Pugh cirrhosis can be
tolerated satisfactorily with higher incidence of the postoperative complications specially
bleeding and infection problems.
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