Observational Study
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World J Gastroenterol. Sep 21, 2014; 20(35): 12608-12614
Published online Sep 21, 2014. doi: 10.3748/wjg.v20.i35.12608
Cardiac surgery in patients with liver cirrhosis: Risk factors for predicting mortality
Cheng-Hsin Lin, Ron-Bin Hsu
Cheng-Hsin Lin, Ron-Bin Hsu, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan
Author contributions: Lin CH and Hsu RB contributed equally to the manuscript, drafting the article and revised it critically; all authors approved the final version for publication.
Correspondence to: Ron-Bin Hsu, MD, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, No.7, Chung-Shan S. Rd., Taipei 100, Taiwan. ronbin@ntuh.gov.tw
Telephone: +886-2-2312-3456 Fax: +886-2-23410933
Received: October 28, 2013
Revised: December 25, 2013
Accepted: February 16, 2014
Published online: September 21, 2014
Processing time: 326 Days and 11.4 Hours
Abstract

AIM: To evaluate the results of cardiac surgery in cirrhotic patients and to find the predictors of early and late mortality.

METHODS: We included 55 consecutive cirrhotic patients undergoing cardiac surgery between 1993 and 2012. Child-Turcotte-Pugh (Child) classification and Model for End-Stage Liver Disease (MELD) score were used to assess the severity of liver cirrhosis. The online EuroSCORE II calculator was used to calculate the logistic EuroSCORE in each patient. Stepwise logistic regression analysis was used to identify the risk factors for mortality at different times after surgery. Multivariate Cox proportional hazard models were applied to estimate the hazard ratios (HR) of predictors for mortality. The Kaplan-Meier method was used to generate survival curves, and the survival rates between groups were compared using the log-rank test.

RESULTS: There were 30 patients in Child class A, 20 in Child B, and five in Child C. The hospital mortality rate was 16.4%. The actuarial survival rates were 70%, 64%, 56%, and 44% at 1, 2, 3, and 5 years after surgery, respectively. There were no significant differences in major postoperative complications, and early and late mortality between patients with mild and advanced cirrhosis. Multivariate logistic regression showed preoperative serum bilirubin, the EuroSCORE and coronary artery bypass grafting (CABG) were associated with early and late mortality; however, Child class and MELD score were not. Cox regression analysis identified male gender (HR = 0.319; P = 0.009), preoperative serum bilirubin (HR = 1.244; P = 0.044), the EuroSCORE (HR = 1.415; P = 0.001), and CABG (HR = 3.344; P = 0.01) as independent risk factors for overall mortality.

CONCLUSION: Advanced liver cirrhosis should not preclude patients from cardiac surgery. Preoperative serum bilirubin, the EuroSCORE, and CABG are major predictors of early and late mortality.

Keywords: Cardiac surgery; Liver cirrhosis; Risk factor

Core tip: Patients with liver cirrhosis are considered high-risk for cardiac surgery. Information on risk factors to predict operative results was limited. We sought to evaluate the operative results of cardiac surgery in cirrhotic patients and to find the predictors of early and late mortality. Child-Turcotte-Pugh (Child) classification and Model for End-Stage Liver Disease (MELD) score were used to assess the severity of liver cirrhosis. Advanced liver cirrhosis with Child B and C and high MELD score should not preclude patients from cardiac surgery. Preoperative serum bilirubin, the EuroSCORE, and coronary artery bypass grafting are major predictors of early and late mortality.