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Ang SP, Chia JE, Iglesias J, Usman MH, Krittanawong C. Coronary Intervention Outcomes in Patients with Liver Cirrhosis. Curr Cardiol Rep 2025; 27:2. [PMID: 39754700 PMCID: PMC11700054 DOI: 10.1007/s11886-024-02163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2024] [Indexed: 01/06/2025]
Abstract
PURPOSE OF REVIEW This review assesses the outcomes of coronary interventions in patients with liver cirrhosis and coronary artery disease (CAD), focusing on the clinical challenges posed by cirrhosis-related hemodynamic and coagulopathic changes. It highlights essential considerations for managing these patients, who have an increased risk of adverse events during coronary procedures. RECENT FINDINGS Recent studies have shown that patients with liver cirrhosis undergoing PCI experience significantly higher mortality rates compared to non-cirrhotic patients, particularly in the context of STEMI and NSTEMI. Coagulopathy and thrombocytopenia increase the risk of bleeding and vascular complications during interventions. Radial access has been suggested as a safer alternative to femoral access in these patients due to reduced bleeding complications. Additionally, contrast-induced nephropathy (CIN) is a prevalent risk, with cirrhotic patients demonstrating higher rates of acute kidney injury post-PCI. Preventive strategies such as minimizing contrast exposure and utilizing intravascular ultrasound (IVUS) are recommended. Managing CAD in cirrhotic patients requires careful consideration of their unique pathophysiological state. Higher in-hospital mortality, bleeding risks, and vascular complications necessitate tailored procedural strategies, such as radial access and contrast minimization. The balance between thrombotic and bleeding risks is critical in decision-making, with IVUS and hydration strategies being promising approaches. Further research is required to optimize treatment protocols and improve long-term outcomes for this high-risk population.
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Affiliation(s)
- Song Peng Ang
- Department of Medicine, Rutgers Health/Community Medical Center, Toms River, NJ, USA.
| | - Jia Ee Chia
- Department of Medicine, Texas Tech University Health Science Center, El Paso, TX, USA
| | - Jose Iglesias
- Department of Medicine, Rutgers Health/Community Medical Center, Toms River, NJ, USA
- Department of Medicine, Hackensack Meridian School of Medicine, Nutley, NJ, USA
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Pagano G, Koshy AN, Chadha R, VanWagner LB, Crespo G. Management of the liver transplant candidate with high cardiac risk: Multidisciplinary best practices and recommendations. Liver Transpl 2024; 30:1304-1315. [PMID: 38727607 DOI: 10.1097/lvt.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 05/03/2024] [Indexed: 07/19/2024]
Abstract
In a setting characterized by a growing prevalence of patients with alcohol-associated and metabolic dysfunction-associated steatotic liver diseases, coupled with an aging patient demographic, the incidence of cardiac comorbidities in liver transplant candidates is on the rise. These comorbidities not only pose barriers to transplant eligibility but also impact the intraoperative course and affect posttransplant outcomes. As such, there is a significant need to optimize the clinical management of these cardiac comorbidities. However, there is a scarcity of evidence regarding the best practices for managing cardiac comorbidities such as coronary and valvular heart diseases, arrhythmia, and cardiomyopathy in this population, both before and during transplant surgery. These conditions necessitate a coordinated and multidisciplinary approach to care. In this manuscript, we conduct a comprehensive review of the most recent evidence pertaining to the preoperative and intraoperative management of these cardiac comorbidities in liver transplant candidates. Our aim is to provide recommendations that improve and standardize their clinical care.
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Affiliation(s)
- Giulia Pagano
- Department of Hepatology, Hospital Clínic, Liver Transplant Unit, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Anoop N Koshy
- Department of Cardiology and Victorian Liver Transplant Unit, Austin Health, University of Melbourne, Victoria, Australia
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gonzalo Crespo
- Department of Hepatology, Hospital Clínic, Liver Transplant Unit, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
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Harinstein ME, Gandolfo C, Gruttadauria S, Accardo C, Crespo G, VanWagner LB, Humar A. Cardiovascular disease assessment and management in liver transplantation. Eur Heart J 2024; 45:4399-4413. [PMID: 39152050 DOI: 10.1093/eurheartj/ehae502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/21/2024] [Accepted: 07/25/2024] [Indexed: 08/19/2024] Open
Abstract
The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.
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Affiliation(s)
- Matthew E Harinstein
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caterina Gandolfo
- Unit of Interventional Cardiology, Department of Cardiothoracic Surgery, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Caterina Accardo
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Yeo YH, Thong JY, Tan MC, Ang QX, San BJ, Tan BEX, Chatterjee A, Lee K. Risk factors for early mortality following transcatheter edge-to-edge repair of mitral regurgitation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00626-2. [PMID: 39168760 DOI: 10.1016/j.carrev.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/20/2024] [Accepted: 08/13/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND While transcatheter edge-to-edge repair (TEER) with MitraClip is increasingly used, data on the risk stratification for assessing early mortality after this procedure are scarce. OBJECTIVE This study aimed to assess early mortality and analyze the risk factors of early mortality among patients who underwent TEER. METHODS Using the all-payer, nationally representative Nationwide Readmissions Database, our study included patients aged 18 years or older who had TEER between January 2017 and November 2020. We categorized the cohort into two groups depending on the occurrence of early mortality (death within 30 days after the procedure). Based on the ICD-10, we identified the trend of early mortality after TEER and further analyzed the risk factors associated with early mortality. RESULTS A total of 15,931 patients who had TEER were included; 292 (1.8 %) with early mortality and 15,639 (98.2 %) without. There was a decreasing trend in early mortality from 2.8 % in the first quarter of 2017 to 1.2 % in the fourth quarter of 2020, but it was not statistically significant (p = 0.18). In multivariable analysis, the independent risk factors for early mortality were chronic kidney disease not requiring dialysis (adjusted odds ratio [aOR]: 1.57; 95 % confidence interval [CI]: 1.11-2.22, p = 0.01), end-stage renal disease (aOR: 2.34; CI: 1.44-3.79, p < 0.01), chronic liver disease (aOR: 4.90; CI: 3.29-7.29, p < 0.01), coagulation disorder (aOR: 3.42; CI: 2.35-5.03, p < 0.01), systolic heart failure (aOR: 2.81; CI: 1.34-5.90, p < 0.01), diastolic heart failure (aOR: 2.69; CI: 1.24-5.84, p = 0.01) and unspecified heart failure (aOR: 3.23; CI: 1.49-7.01, p < 0.01). Among those who died during 30-day readmission following TEER, the most common cardiac cause and non-cardiac-cause of readmission were heart failure (18.2 %) and infection (26.6 %), respectively. CONCLUSION The early mortality following TEER was low at 1.8 %. The independent risk factors associated with early mortality were chronic kidney disease (including end-stage renal disease), chronic liver disease, coagulation disorder, and heart failure (both systolic and diastolic).
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Affiliation(s)
- Yong-Hao Yeo
- Department of Internal Medicine-Pediatrics, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | | | - Min-Choon Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA; Department of Internal Medicine, New York Medical College at Saint Michael's Medical Center, Newark, NJ, USA
| | - Qi-Xuan Ang
- Department of Internal Medicine, Sparrow Health System and Michigan State University, East Lansing, MI, USA
| | | | - Bryan E-Xin Tan
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Arka Chatterjee
- Department of Cardiovascular Medicine, University of Arizona, Tucson, AZ, USA
| | - Kwan Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA.
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Siraw BB, Patel P, Mehadi AY, Zaher EA, Tafesse YT. Association Between Chronic Liver Disease and Adverse In-Hospital Outcomes in Patients Undergoing CABG: A Propensity Score-Matched Analysis. Am J Cardiol 2024; 222:65-71. [PMID: 38642867 DOI: 10.1016/j.amjcard.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/18/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
Despite a 30% decrease in the rate over the last decade, coronary artery bypass graft (CABG) surgery remains a common major surgical procedure with significant morbidity and mortality. Chronic liver disease (CLD) patients, with increased survival rates because of medical advancements, are now frequently being considered for CABG, bearing higher perioperative risks. This study investigates the association between CLD and in-hospital outcomes in CABG patients using retrospective data from the National Inpatient Sample database (2016 to 2020) including 7,945 CLD patients who underwent CABG that were propensity score-matched with an equivalent number of patients without CLD who underwent CABG. Clinical variables were extracted using corresponding International Classification of Diseases, Tenth Revision codes, and multivariable logistic and linear regression models were used to assess in-hospital mortality, complications, and length of stay. The overall mortality rate was 5.5% (8.6% in the CLD group with cirrhosis, 5.9% CLD group without cirrhosis, and 2.8% in the non-CLD group, p <0.001). CLD with cirrhosis was associated with higher odds of mortality (adjusted odds ratio = 4.21, 95% confidence interval 3.61 to 4.94) and length of stay (β = 1.03, 95% confidence interval 1.01 to 1.05). CLD patients with cirrhosis demonstrated higher odds of perioperative cardiac complications (cardiac arrest, ventricular arrhythmias, tamponade, and shock), thromboembolic events, gastrointestinal bleeding, bowel ischemia, acute kidney injury, pneumonia, and sepsis. This study reveals a substantial impact of CLD on adverse outcomes in CABG patients, emphasizing the need for tailored preoperative assessments and postoperative care.
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Affiliation(s)
- Bekure B Siraw
- Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, Illinois.
| | - Parth Patel
- Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, Illinois
| | - Abdulrahim Y Mehadi
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | - Eli A Zaher
- Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, Illinois
| | - Yordanos T Tafesse
- Department of Hematology/Oncology, Biological Sciences Division, University of Chicago, Chicago, Illinois
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Nugraha YK, Maimunah U. Perioperative management of constrictive pericarditis with cardiac cirrhosis: A case report. Int J Surg Case Rep 2024; 120:109843. [PMID: 38848659 PMCID: PMC11192800 DOI: 10.1016/j.ijscr.2024.109843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024] Open
Abstract
INTRODUCTION The interactions between the heart and liver have been known for a long time, pericarditis constrictive could cause congestive hepatopathy via right-sided heart failure. Liver cirrhosis correlates with a high risk of mortality so perioperative management greatly influences outcomes. CASE PRESENTATION An Indonesian man, 50 years old, complained of breath shortness. The patient had a history of pulmonary tuberculosis and was declared cured 30 years ago. The patient began experiencing fatigue 14 years ago, and the patient was diagnosed with constrictive pericarditis 5 years ago. Currently, the patient has an increased jugular venous pressure of 9 cmH2O and abnormal laboratory indicators, including a platelet count of 121,000/μL, albumin count of 3.41 g/L, direct bilirubin count of 0.7 mg/dL, total bilirubin count of 1.4 mg/dL, and INR of 1.4. Echocardiography revealed left ventricle hypertrophy, diastolic dysfunction, and right ventricle failure. Cardiac CT scan showed pericardial calcification. Abdominal ultrasound showed liver congestive and splenomegaly. Transient elastography showed severe fibrosis in liver and stiffness in spleen. The patient underwent pericardiectomy with CTP score of 6 and MELD of 12. The surgery was successful, and the complaint was reduced. The patient experienced an improvement in his condition and able to carry out activities well after 2 years post-surgery. DISCUSSION The patient has no contraindications to pericardiectomy, CTP class A (5-6) and MELD score <13.5 has a low risk of mortality. CONCLUSION CTP and MELD scores predict life expectancy in post-surgery cardiac cirrhosis patients.
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Affiliation(s)
- Yudha Klahan Nugraha
- Study Program of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ummi Maimunah
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
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He K, Pang K, Yan X, Wang Q, Wu D. New sights in ectopic varices in portal hypertension. QJM 2024; 117:397-412. [PMID: 38321102 DOI: 10.1093/qjmed/hcae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/31/2024] [Indexed: 02/08/2024] Open
Abstract
Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.
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Affiliation(s)
- K He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - K Pang
- Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - X Yan
- Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Q Wang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - D Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Yamasaki S, Sakamoto T, Endo A, Yoshitomi H, Tanabe K. Combinational elastography prior to pericardiectomy to assess liver condition in patients with constrictive pericarditis. J Cardiol Cases 2024; 29:254-257. [PMID: 38826762 PMCID: PMC11143733 DOI: 10.1016/j.jccase.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/24/2024] [Accepted: 02/07/2024] [Indexed: 06/04/2024] Open
Abstract
A 68-year-old man was diagnosed with pericarditis associated with immunoglobulin G4-related disease and was administered prednisolone 2 years prior to presentation. During the process of tapering off from prednisolone 1 year later, edema of the lower legs and pleural effusion worsened. He gradually developed dyspnea on exertion, and laboratory examinations revealed elevated liver enzyme levels. Diuretics were administered; however, the symptoms did not resolve. Transthoracic echocardiography and cardiac catheterization revealed findings consistent with those of constrictive pericarditis. Pericardiectomy was considered and the perioperative risks due to possible recovery from liver dysfunction were discussed. Combinational elastography was subsequently performed. The results indicated the absence of liver fibrosis, suggesting that liver dysfunction was attributable to liver congestion; thus, the liver dysfunction was considered reversible. Subsequently, pericardiectomy was performed. Given that constrictive pericarditis can lead to liver dysfunction due to congestion, the perioperative risk is often controversial when considering surgical interventions. Learning objective Combinational elastography may be useful in the preoperative evaluation of patients with cardiac diseases complicated by liver dysfunction to distinguish liver fibrosis, understand the pathogenesis of liver dysfunction, and determine subsequent treatment strategies.
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Affiliation(s)
- Seita Yamasaki
- Division of Cardiology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Takahiro Sakamoto
- Department of Heart Failure and Transplant, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akihiro Endo
- Division of Cardiology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Hiroyuki Yoshitomi
- Department of Clinical Laboratory, Shimane University Hospital, Shimane, Japan
| | - Kazuaki Tanabe
- Division of Cardiology, Shimane University Faculty of Medicine, Shimane, Japan
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Nakamura H, Miura Y, Yoshida K, Saito R, Orihashi K. Comprehensive Treatment of Total Arch Replacement in a Patient With Liver Cirrhosis: A Case Report. Cureus 2024; 16:e60365. [PMID: 38882984 PMCID: PMC11178364 DOI: 10.7759/cureus.60365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
A 78-year-old woman with liver cirrhosis due to chronic hepatitis C visited our department for treatment of a thoracic aortic aneurysm. Her Child-Pugh classification was class A, and her model for end-stage liver (MELD) disease score was 8. As she also had thrombocytopenia associated with splenomegaly and esophageal varices, endoscopic injection sclerotherapy and partial splenic embolization were performed before total arch replacement surgery for treating esophageal varices to reduce the bleeding risk during transesophageal echocardiography and for thrombocytopenia, respectively. After endoscopic injection sclerotherapy and partial splenic embolization, the platelet count increased; hence, total arch replacement surgery was performed. By combining partial splenic embolization and endoscopic injection sclerotherapy, we were able to safely perform transesophageal echocardiography and total arch replacement surgery in the perioperative period.
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Affiliation(s)
- Hiromasa Nakamura
- Cardiovascular Surgery, Kochi Medical University Hospital, Nankoku, JPN
| | - Yujiro Miura
- Cardiovascular Surgery, Kochi Medical University Hospital, Nankoku, JPN
| | - Keisuke Yoshida
- Cardiovascular Surgery, Kochi Medical University Hospital, Nankoku, JPN
| | - Ren Saito
- Cardiovascular Disease, Kochi Medical University Hospital, Nankoku, JPN
| | - Kazumasa Orihashi
- Liaison Healthcare Engineering, Kochi Medical University Hospital, Nankoku, JPN
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Cizmic A, Rahmanian PB, Gassa A, Kuhn E, Mader N, Wahlers T. Prognostic value of ascites in patients with liver cirrhosis undergoing cardiac surgery. J Cardiothorac Surg 2023; 18:302. [PMID: 37898812 PMCID: PMC10613375 DOI: 10.1186/s13019-023-02393-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/30/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Mild or moderate liver cirrhosis increases the risk of complications after cardiac surgery. Ascites is the most common complication associated with liver cirrhosis. However, the prognostic value of ascites on postoperative morbidity and mortality after cardiac surgery remains uninvestigated. METHODS A retrospective study included 69 patients with preoperatively diagnosed liver cirrhosis who underwent cardiac surgery between January 2009 and January 2018 at the Department of Cardiothoracic Surgery, University Hospital of Cologne, Germany. The patients were divided into ascites and non-ascites groups based on preoperatively diagnosed ascites. Thirty-day mortality, postoperative complications, length of stay, and blood transfusions were analyzed postoperatively. RESULTS Out of the total of 69 patients, 14 (21%) had preoperatively diagnosed ascites. Ascites group had more postoperative complications such as blood transfusions (packed red blood cells: 78.6% vs. 40.0%, p = 0.010; fresh frozen plasma: 57.1% vs. 29.1%, p = 0.049), acute kidney injury (78.6% vs. 45.5%, p = 0.027), longer ICU stay (8 vs. 3 days, p = 0.044) with prolonged mechanical ventilation (57.1% vs. 23.6%, p = 0.015) and tracheotomy (28.6% vs. 3.6%, p = 0.003). The 30-day mortality rate was significantly higher in the ascites group than in the non-ascites group (35.7% vs. 5.5%, p = 0.002). CONCLUSION Ascites should be implemented in preoperative risk score assessments in cirrhotic patients undergoing cardiac surgery. Preoperative treatment of ascites could reduce the negative impact of ascites on postoperative complications after cardiac surgery. However, this needs to be thoroughly investigated in prospective randomized clinical trials.
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Affiliation(s)
- Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Asmae Gassa
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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Liu F, Li ZW, Liu XR, Liu XY, Yang J. The Effect of Liver Cirrhosis on Patients Undergoing Cardiac Surgery. Glob Heart 2023; 18:54. [PMID: 37811135 PMCID: PMC10558028 DOI: 10.5334/gh.1270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/08/2023] [Indexed: 10/10/2023] Open
Abstract
The aim of this study was to investigate the impact of liver cirrhosis (LC) on postoperative complications and long-term outcomes in patients who underwent cardiac surgery. Three databases, including PubMed, Embase, and the Cochrane Library, were searched on July 24, 2022. A total of 1,535,129 patients were enrolled in the seven included studies for analysis. According to our analysis, LC was a risk factor for postoperative overall complications (OR = 1.48, 95% CI = 1.21 to 1.81, I2 = 90.35%, P = 0.00 < 0.1). For various complications, more patients developed pulmonary (OR = 1.86, 95% CI = 1.21 to 2.87, I2 = 90.79%, P = 0.00 < 0.1), gastrointestinal (OR = 2.03, 95% CI = 1.32 to 3.11, I2 = 0.00%, P = 0.00 < 0.05), renal (OR = 2.20, 95% CI = 1.41 to 3.45, I2 = 91.60%, P = 0.00 < 0.1), neurological (OR = 1.14, 95% CI = 1.03 to 1.26, I2 = 7.35%, P = 0.01 < 0.05), and infectious (OR = 2.02, 95% CI = 1.17 to 3.50, I2 = 92.37%, P = 0.01 < 0.1) complications after surgery in the LC group. As for cardiovascular (OR = 1.07, 95% CI = 0.85 to 1.35, I2 = 75.23%, P = 0.58 > 0.1) complications, there was no statistical significance between the 2 groups. As for long-term outcomes, we found that in-hospital death (OR = 2.53, 95% CI = 1.86 to 3.20, I2 = 44.58%, P = 0.00 < 0.05) and death (OR = 3.31, 95% CI = 1.54 to 5.07, I2 = 93.81%, P = 0.00 < 0.1) in the LC group were higher than the non-LC group. LC was a risk factor for cardiac surgery. Patients with LC who would undergo cardiac surgery should be fully assessed for the risks of cardiac surgery. Similarly, the surgeon should assess the patient's liver function before surgery.
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Affiliation(s)
- Fei Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-Wei Li
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xu-Rui Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Yang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Emenena I, Emenena B, Kweki AG, Aiwuyo HO, Osarenkhoe JO, Iloeje UN, Ilerhunmwuwa N, Torere BE, Akinti O, Akere A, Casimir OE. Model for End Stage Liver Disease (MELD) Score: A Tool for Prognosis and Prediction of Mortality in Patients With Decompensated Liver Cirrhosis. Cureus 2023; 15:e39267. [PMID: 37342753 PMCID: PMC10278970 DOI: 10.7759/cureus.39267] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Decompensated liver disease has become a common occurrence in medical wards. It has become the third most common cause of death in medical wards. This high mortality rate has become a matter of concern. It is important that a reliable scoring system helps to stratify patients with liver cirrhosis who will require liver transplantation. OBJECTIVE To determine the value of the Model for End-Stage Liver Disease (MELD) score in assessing the mortality of patients with decompensated liver cirrhosis over one month period (30 days). METHODS AND MATERIALS A longitudinal study was conducted. A total of 110 patients diagnosed with decompensated liver cirrhosis were recruited from the gastroenterology clinic and medical wards of the University of Benin Teaching Hospital (UBTH), Benin City. The patients were recruited consecutively and met the inclusion criteria for the study. Demographic data, history, clinical, biochemical, ultrasonographic, and liver biopsy findings were evaluated in the patients who participated in this study. Results: The mean age of the patients was 57 ± 11.06 years. Out of the 110 study participants, a 2.9:1 male-to-female ratio was appreciated in the patient population, with a total of 82 males and 28 females. Multiple logistic regression analysis identified MELD scores as an independent predictor of mortality in the studied patients. Predictive values of the MELD score for 1-month mortality which was analyzed using the receiver operating characteristic (ROC) curves showed that the MELD score had a sensitivity of 72.2% and positive predictive value of 93.6% with an area under the curve of 0.926 for all-cause mortality among decompensated liver cirrhosis patients. CONCLUSION MELD score is a good predictor of mortality among patients with decompensated liver cirrhosis over a 1-month (30 days) period.
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Affiliation(s)
- Isioma Emenena
- Internal Medicine/Gastroenterology, Delta State University Teaching Hospital, Oghara, NGA
| | | | - Anthony G Kweki
- Internal Medicine/Cardiology, Colchester Hospital, ESNEFT, Colchester, GBR
| | - Henry O Aiwuyo
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - John O Osarenkhoe
- Medicine and Surgery, Igbinedion University Teaching Hospital, Benin City, NGA
| | - Ugoeze N Iloeje
- Internal Medicine/Cardiology, Federal Medical Centre, Yenagoa, NGA
| | | | | | - Oluwasegun Akinti
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Adegboyega Akere
- Medicine, College of Medicine, University of Ibadan, Ibadan, NGA
| | - Omuemu E Casimir
- Internal Medicine, University of Benin, Benin City, NGA
- Medicine, University of Benin Teaching Hospital, Benin City, NGA
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13
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Pathare P, Elbayomi M, Weyand M, Griesbach C, Harig F. MELD-score for risk stratification in cardiac surgery. Heart Vessels 2023:10.1007/s00380-023-02262-9. [PMID: 37004541 PMCID: PMC10372113 DOI: 10.1007/s00380-023-02262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/15/2023] [Indexed: 04/04/2023]
Abstract
The outcome of the patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is also influenced by the renal and hepatic organ functions. Risk stratification, using scores such as EURO Score II or STS Short-Term Risk Calculator for patients undergoing cardiac surgery with cardiopulmonary bypass, ignores the quantitative renal and hepatic function; therefore, MELD-Score was applied in these cases. We retrospectively examined patient data using the MELD score as a predictor of mortality. To perform a univariate analysis of the data, patients were classified into three groups based on the MELD Score: MELD < 10 (Group 1), MELD 10 to 19 (Group 2), and MELD ≥ 20 (Group 3). A total of 11,477 participants were included in the study, though several patients with either missing MELD scores or lack of creatinine, bilirubin, or INR levels were dropped from the original cohort. Eventually, 10,882 patients were included in the analysis. The primary outcome was defined as postoperative, in-hospital mortality. Secondary outcomes such as postoperative bleeding, including the requirement for repeat thoracotomy, postoperative neurological complications, and assessment of catecholamines on weaning from cardiopulmonary bypass/ requirement of mechanical circulatory support were examined. A higher MELD score was associated with increased postoperative mortality. Patients with MELD > 20 experienced a 31.2% postoperative mortality, compared to Group 1 (4.6%) and Group 2 (17.5%). The highest rates of postoperative bleeding (13.8%) and, repeat thoracotomy (13.2%) & postoperative pneumonia (17.4%) were seen in Group 3 (threefold increase when compared to Group 1, renal failure requiring dialysis (N = 235, 2.7% in Group 1 v/s N = 78, 22.9% in Group 3) or requiring high dose catecholamines post-operatively or mechanical circulatory support (IABP/ECLS). Incidentally, an increased MELD Score was not associated with a significant increase in the postoperative incidence of stroke/TIA or the presence of sternal wound infections/complications. A higher mortality was observed in patients with reduced liver and renal function, with a significant increase in patients with a MELD score > 20. As the current risk stratification scores do not consider this, we recommend applying the MELD score before considering patients for cardiac surgery.
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Affiliation(s)
- Presheet Pathare
- Universitätsklinikum Erlangen, Herzchirurgische Klinik, Krankenhaus Straße, 12, 91054, Erlangen, Germany.
| | - Mohamed Elbayomi
- Universitätsklinikum Erlangen, Herzchirurgische Klinik, Krankenhaus Straße, 12, 91054, Erlangen, Germany
| | - Michael Weyand
- Universitätsklinikum Erlangen, Herzchirurgische Klinik, Krankenhaus Straße, 12, 91054, Erlangen, Germany
| | - Colin Griesbach
- Chair of Spatial Data Science and Statistical Learning, Georg-August-Unversität Göttingen, Wilhelmsplatz, 1, 37073, Göttingen, Germany
| | - Frank Harig
- Universitätsklinikum Erlangen, Herzchirurgische Klinik, Krankenhaus Straße, 12, 91054, Erlangen, Germany
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14
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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15
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Khandait H, Jaiswal V, Hanif M, Shrestha AB, Iturburu A, Shah M, Ishak A, Garimella V, Ang SP, Mathew M. Percutaneous Coronary Intervention Outcomes in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10030092. [PMID: 36975856 PMCID: PMC10059068 DOI: 10.3390/jcdd10030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/01/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
There is a paucity of data and minimal literature on outcomes of percutaneous coronary intervention (PCI) among liver cirrhosis patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the clinical outcomes among liver cirrhosis patients post-PCI. We conducted a comprehensive literature search in the PubMed, Embase, Cochrane, and Scopus databases for relevant studies. Effect sizes were pooled using the DerSimonian and Laird random-effects model as an odds ratio (OR) with 95% confidence intervals (CI). A total of 3 studies met the inclusion criteria, providing data from 10,705,976 patients. A total of 28,100 patients were in the PCI + Cirrhosis group and 10,677,876 patients were in the PCI-only group. The mean age of patients with PCI + Cirrhosis and PCI alone was 63.45 and 64.35 years. The most common comorbidity was hypertension among the PCI + Cirrhosis group compared with PCI alone (68.15% vs. 73.6%). Cirrhosis patients post-PCI were had higher rates of in-hospital mortality (OR, 4.78 (95%CI: 3.39–6.75), p < 0.001), GI bleeding (OR, 1.91 (95%CI:1.83–1.99), p < 0.001, I2 = 0%), stroke (OR, 2.48 (95%CI:1.68–3.66), p < 0.001), AKI (OR, 3.66 (95%CI: 2.33–6.02), p < 0.001), and vascular complications (OR, 1.50 (95%CI: 1.13–1.98), p < 0.001) compared with the PCI group without cirrhosis. Patients with cirrhosis are at a high risk for mortality and adverse outcomes post-PCI procedure compared to the PCI-only group of patients.
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Affiliation(s)
| | - Vikash Jaiswal
- Department of Research, JCCR Cardiology Research, Varanasi 221005, India
- Correspondence:
| | - Muhammad Hanif
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | | | - Alisson Iturburu
- Department of Medicine, Universidad de Guayaquil, Guayas 090514, Ecuador
| | - Maitri Shah
- Department of Research and Academic Affairs, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Angela Ishak
- Department of Research and Academic Affairs, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Vamsi Garimella
- Department of Internal Medicine, University of Miami (Holy Cross), Miami, FL 33136, USA
| | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, Toms River, NJ 08755, USA
| | - Midhun Mathew
- Trinitas Regional Medical Center/RWJ Barnabas Health, Elizabeth, NJ 07202, USA
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16
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Morris SM, Abbas N, Osei-Bordom DC, Bach SP, Tripathi D, Rajoriya N. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Rev Gastroenterol Hepatol 2023; 17:155-173. [PMID: 36594658 DOI: 10.1080/17474124.2023.2163627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Patients with liver disease and portal hypertension frequently require surgery carrying high morbidity and mortality. Accurately estimating surgical risk remains challenging despite improved medical and surgical management. AREAS COVERED This review aims to outline a comprehensive approach to preoperative assessment, appraise methods used to predict surgical risk, and provide an up-to-date overview of outcomes for patients with cirrhosis undergoing non-hepatic surgery. EXPERT OPINION Robust preoperative, individually tailored, and precise risk assessment can reduce peri- and postoperative complications in patients with cirrhosis. Established prognostic scores aid stratification, providing an estimation of postoperative mortality, albeit with limitations. VOCAL-Penn Risk Score may provide greater precision than established liver severity scores. Amelioration of portal hypertension in advance of surgery may be considered, with prospective data demonstrating hepatic venous pressure gradient as a promising surrogate marker of postoperative outcomes. Morbidity and mortality vary between types of surgery with further studies required in patients with more advanced liver disease. Patient-specific considerations and practicing precision medicine may allow for improved postoperative outcomes.
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Affiliation(s)
- Sean M Morris
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - Nadir Abbas
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Daniel-Clement Osei-Bordom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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17
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Doycheva I, Izzy M, Watt KD. Cardiovascular assessment before liver transplantation. CARDIO-HEPATOLOGY 2023:309-326. [DOI: 10.1016/b978-0-12-817394-7.00005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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18
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Kirov H, Caldonazo T, Audisio K, Rahouma M, Robinson NB, Cancelli G, Soletti GJ, Demetres M, Ibrahim M, Faerber G, Gaudino M, Doenst T. Association of liver dysfunction with outcomes after cardiac surgery-a meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6883890. [PMID: 36477871 PMCID: PMC9741516 DOI: 10.1093/icvts/ivac280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to perform a meta-analysis of studies reporting outcomes in patients with liver dysfunction addressed by the model of end-stage liver disease and Child-Turcotte-Pugh scores undergoing cardiac surgery. METHODS A systematic literature search was conducted to identify contemporary studies reporting short- and long-term outcomes in patients with liver dysfunction compared to patients with no or mild liver dysfunction undergoing cardiac surgery (stratified in high and low score group based on the study cut-offs). Primary outcome was perioperative mortality. Secondary outcomes were perioperative neurological events, prolonged ventilation, sepsis, bleeding and/or need for transfusion, acute kidney injury and long-term mortality. RESULTS A total of 33 studies with 48 891 patients were included. Compared with the low score group, being in the high score group was associated with significantly higher risk of perioperative mortality [odds ratio (OR) 3.72, 95% confidence interval (CI) 2.75-5.03, P < 0.001]. High score group was also associated with a significantly higher rate of perioperative neurological events (OR 1.49, 95% CI 1.30-1.71, P < 0.001), prolonged ventilation (OR 2.45, 95% CI 1.94-3.09, P < 0.001), sepsis (OR 3.88, 95% CI 2.07-7.26, P < 0.001), bleeding and/or need for transfusion (OR 1.95, 95% CI 1.43-2.64, P < 0.001), acute kidney injury (OR 3.84, 95% CI 2.12-6.98, P < 0.001) and long-term mortality (incidence risk ratio 1.29, 95% CI 1.14-1.46, P < 0.001). CONCLUSIONS The analysis suggests that liver dysfunction in patients undergoing cardiac surgery is independently associated with higher risk of short and long-term mortality and also with an increased occurrence of various perioperative adverse events.
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Affiliation(s)
| | | | - Katia Audisio
- Department of Cardiothoracic Surgery at New York Presbyterian, Weill Cornell Medical Center, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery at New York Presbyterian, Weill Cornell Medical Center, USA
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery at New York Presbyterian, Weill Cornell Medical Center, USA
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery at New York Presbyterian, Weill Cornell Medical Center, USA
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery at New York Presbyterian, Weill Cornell Medical Center, USA
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, NY, USA,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Germany
| | - Mario Gaudino
- Department of Cardiothoracic Surgery at New York Presbyterian, Weill Cornell Medical Center, USA
| | - Torsten Doenst
- Corresponding author. Department of Cardiothoracic Surgery, University of Jena, 101 Erlanger Allee, 07747 Jena, Germany, Tel: +49-3641-9322-901; fax: +49-3641-9322-902; e-mail: (T. Doenst)
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19
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Lopez-Delgado JC, Putzu A, Landoni G. The importance of liver function assessment before cardiac surgery: A narrative review. Front Surg 2022; 9:1053019. [PMID: 36561575 PMCID: PMC9764862 DOI: 10.3389/fsurg.2022.1053019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
The demand for cardiac surgery procedures is increasing globally. Thanks to an improvement in survival driven by medical advances, patients with liver disease undergo cardiac surgery more often. Liver disease is associated with the development of heart failure, especially in patients with advanced cirrhosis. Cardiovascular risk factors can also contribute to the development of both cardiomyopathy and liver disease and heart failure itself can worsen liver function. Despite the risk that liver disease and cirrhosis represent for the perioperative management of patients who undergo cardiac surgery, liver function is often not included in common risk scores for preoperative evaluation. These patients have worse short and long-term survival when compared with other cardiac surgery populations. Preoperative evaluation of liver function, postoperative management and close postoperative follow-up are crucial for avoiding complications and improving results. In the present narrative review, we discuss the pathophysiological components related with postoperative complications and mortality in patients with liver disease who undergo cardiac surgery and provide recommendations for the perioperative management.
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Affiliation(s)
- Juan C. Lopez-Delgado
- Hospital Clinic de Barcelona, Area de Vigilancia Intensiva (ICMiD), Barcelona, Spain,IDIBELL (Institut d’Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L’Hospitalet de Llobregat, Barcelona, Spain,Correspondence: Juan C. Lopez-Delgado Alessandro Putzu
| | - Alessandro Putzu
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland,Correspondence: Juan C. Lopez-Delgado Alessandro Putzu
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy,Vita-Salute San Raffaele University, Milan, Italy
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20
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Wijarnpreecha K, Fontana RJ. Watch out for the Saurkraut: Weissella confusa endocarditis in a liver transplant candidate. Clin Liver Dis (Hoboken) 2022; 20:188-193. [PMID: 36523861 PMCID: PMC9745257 DOI: 10.1002/cld.1256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/13/2022] [Accepted: 08/04/2022] [Indexed: 12/15/2022] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Karn Wijarnpreecha
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Robert J. Fontana
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
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21
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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22
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Chen J, Song W, Wei L. Risk stratification for isolated tricuspid valve surgery: Still on the way. JTCVS OPEN 2022; 11:89-90. [PMID: 36172433 PMCID: PMC9510854 DOI: 10.1016/j.xjon.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Mizobuchi S, Saito Y, Fujito H, Miyagawa M, Kitano D, Toyama K, Fukamachi D, Okumura Y. Prognostic importance of improving hepatorenal function during hospitalization in acute decompensated heart failure. ESC Heart Fail 2022; 9:3113-3123. [PMID: 35751395 DOI: 10.1002/ehf2.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/16/2022] [Accepted: 06/03/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS The Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) is an established scoring system that reflects hepatorenal function. However, little is known about the prognostic value of changes in MELD-XI score during hospitalization in acute decompensated heart failure (ADHF). METHODS AND RESULTS We prospectively analysed 536 patients admitted for ADHF between January 2018 and December 2019. In the MELD-XI, 9.44 is the lowest possible score and considered to be normal, and values above 9.44 are classified as high. We calculated MELD-XI scores at admission and discharge and used them to divide patients into four groups depending on whether the score was high (>9.44) or normal (9.44) at each time point as follows: normal score at both measurements (persistently normal group, n = 99), high score at admission and normal score at discharge (high-to-normal group, n = 108), normal score at admission and high score at discharge (normal-to-high group, n = 24), and high score at both measurements (persistently high group, n = 305). The persistently high group had higher blood urea nitrogen, creatinine, and N-terminal pro-brain natriuretic peptide levels at both admission and discharge and significantly higher left ventricular end-diastolic, left atrial, right ventricular end-diastolic, and maximal inferior vena cava diameters at discharge. During the median follow-up period of 369 days (Q1, Q3: 97, 576), 231 (43.1%) patients reached the primary endpoint (a composite of all-cause death or re-hospitalization for heart failure). The Kaplan-Meier analysis revealed a significantly higher composite event rate in the persistently high group than in the persistently normal and high-to-normal groups (log-rank test, P < 0.001). Compared with the persistently high group, the high-to-normal group remained significantly associated with lower composite event risk after multivariate adjustment (hazard ratio, 0.30; 95% CI, 0.12-0.69; P = 0.004). CONCLUSIONS Our study suggests that changes in hepatorenal function during hospitalization are associated with the severity of heart failure and systemic congestion and that they provide useful information for predicting clinical outcomes in patients with ADHF.
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Affiliation(s)
- Saki Mizobuchi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuki Saito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hidesato Fujito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masatsugu Miyagawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Daisuke Kitano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuto Toyama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Daisuke Fukamachi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Mahmud N, Fricker Z, Lewis JD, Taddei TH, Goldberg DS, Kaplan DE. Risk Prediction Models for Postoperative Decompensation and Infection in Patients With Cirrhosis: A Veterans Affairs Cohort Study. Clin Gastroenterol Hepatol 2022; 20:e1121-e1134. [PMID: 34246794 PMCID: PMC8741885 DOI: 10.1016/j.cgh.2021.06.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/08/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis have an increased risk of postoperative mortality for a range of surgeries; however, they are also at risk of postoperative complications such as infection and cirrhosis decompensation. To date, there are no prediction scores that specifically risk stratify patients for these morbidities. METHODS This was a retrospective study using data of patients with cirrhosis who underwent diverse surgeries in the Veterans Health Administration. Validated algorithms and/or manual adjudication were used to ascertain postoperative decompensation and postoperative infection through 90 days. Multivariable logistic regression was used to evaluate prediction models in derivation and validation sets using variables from the recently-published Veterans Outcomes and Costs Associated with Liver Disease (VOCAL)-Penn cirrhosis surgical risk scores for postoperative mortality. Models were compared with the Mayo risk score, Model for End-stage Liver Disease (MELD)-sodium, and Child-Turcotte-Pugh (CTP) scores. RESULTS A total 4712 surgeries were included; patients were predominantly male (97.2 %), white (63.3 %), and with alcohol-related liver disease (35.3 %). Through 90 postoperative days, 8.7 % of patients experienced interval decompensation, and 4.5 % infection. Novel VOCAL-Penn prediction models for decompensation demonstrated good discrimination for interval decompensation (C-statistic 0.762 vs 0.663 Mayo vs 0.603 MELD-sodium vs 0.560 CTP; P < .001); however, discrimination was only fair for postoperative infection (C-statistic 0.666 vs 0.592 Mayo [P = .13] vs 0.502 MELD-sodium [P < .001] vs 0.503 CTP [P < .001]). The model for interval decompensation had excellent calibration in both derivation and validation sets. CONCLUSION We report the derivation and internal validation of a novel, parsimonious prediction model for postoperative decompensation in patients with cirrhosis. This score demonstrated superior discrimination and calibration as compared with existing clinical standards, and will be available at www.vocalpennscore.com.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Dar SH, Rahim M, Hosseini DK, Sarfraz K. Impact of liver cirrhosis on ST-elevation myocardial infarction related shock and interventional management, a nationwide analysis. World J Hepatol 2022; 14:766-777. [PMID: 35646267 PMCID: PMC9099112 DOI: 10.4254/wjh.v14.i4.766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/04/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Critical care is rapidly evolving with significant innovations to decrease hospital stays and costs. To our knowledge, there is limited data on factors that affect the length of stay and hospital charges in cirrhotic patients who present with ST-elevation myocardial infarction-related cardiogenic shock (SRCS). AIM To identify the factors that increase inpatient mortality, length of stay, and total hospital charges in patients with liver cirrhosis (LC) compared to those without LC. METHODS This study includes all adults over 18 from the National Inpatient Sample 2017 database. The study consists of two groups of patients, including SRCS with LC and without LC. Inpatient mortality, length of stay, and total hospital charges are the primary outcomes between the two groups. We used STATA 16 to perform statistical analysis. The Pearson's chi-square test compares the categorical variables. Propensity-matched scoring with univariate and multivariate logistic regression generated the odds ratios for inpatient mortality, length of stay, and resource utilization. RESULTS This study includes a total of 35798453 weighted hospitalized patients from the 2017 National Inpatient Sample. The two groups are SRCS without LC (n = 758809) and SRCS with LC (n = 11920). The majority of patients were Caucasian in both groups (67% vs 72%). The mean number of patients insured with Medicare was lower in the LC group (60% vs 56%) compared to the other group, and those who had at least three or more comorbidities (53% vs 90%) were significantly higher in the LC group compared to the non-LC group. Inpatient mortality was also considerably higher in the LC group (28.7% vs 10.63%). Length of Stay (LOS) is longer in the LC group compared to the non-LC group (9 vs 5.6). Similarly, total hospital charges are higher in patients with LC ($147407.80 vs $113069.10, P ≤ 0.05). Inpatient mortality is lower in the early percutaneous coronary intervention (PCI) group (OR: 0.79 < 0.11), however, it is not statistically significant. Both early Impella (OR: 1.73 < 0.05) and early extracorporeal membrane oxygenation (ECMO) (OR: 3.10 P < 0.05) in the LC group were associated with increased mortality. Early PCI (-2.57 P < 0.05) and Impella (-3.25 P < 0.05) were also both associated with shorter LOS compared to those who did not. Early ECMO does not impact the LOS; however, it does increase total hospital charge (addition of $24717.85, P < 0.05). CONCLUSION LC is associated with a significantly increased inpatient mortality, length of stay, and total hospital charges in patients who develop SRCS. Rural and Non-teaching hospitals have significantly increased odds of extended hospital stays and higher adjusted total hospital charges. The Association of LC with worse outcomes outlines the essential need to monitor these patients closely and treat them early on with higher acuity care. Patients with early PCI had both shorter LOS and reduced inpatient mortality, while early Impella was associated with increased mortality and shorter LOS. Early ECMO is associated with increased mortality and higher total hospital charges. This finding should affect the decision to follow through with interventional management in this cohort of patients as it is associated with poor outcomes and immense resource utilization.
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Affiliation(s)
- Sophia Haroon Dar
- Internal Medicine, Hackensack University Medical Center, Hackensack, NJ 07601, United States.
| | - Mehek Rahim
- Internal Medicine, Hackensack University Medical Center, Hackensack, NJ 07601, United States
| | - Davood K Hosseini
- Internal Medicine, Hackensack University Medical Center, Hackensack, NJ 07601, United States
| | - Khurram Sarfraz
- Internal Medicine, Hackensack University Medical Center, Hackensack, NJ 07601, United States
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Saade W, Peruzzi M, Marullo AG. Transcatheter procedures for valvular heart disease in liver cirrhosis patients: too many unanswered questions? Trends Cardiovasc Med 2022; 33:250-251. [PMID: 35292352 DOI: 10.1016/j.tcm.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Wael Saade
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mariangela Peruzzi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Antonino Gm Marullo
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Via di Novella 22, Latina 00199, Italy.
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Jiang SM, Liblik K, Baranchuk A, Payne D, El-Diasty M. CABG in patients with liver cirrhosis: to pump or not to pump? Expert Rev Cardiovasc Ther 2022; 20:95-99. [PMID: 35188033 DOI: 10.1080/14779072.2022.2045195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Coronary artery bypass grafting in patients with established liver cirrhosis is generally associated with poor outcomes. Avoiding cardiopulmonary bypass (CPB) in these patients has not demonstrated any advantage over the use of CPB. We review the current available literature that compared the outcome of both on-pump (ONCABG) and off-pump (OPCAB) techniques in cirrhotic patients in terms of morbidity and mortality. AREAS COVERED A comprehensive search was conducted in the PubMed/MEDLINE and EMBASE databases in January 2021. Articles that reported outcomes of OPCAB and/or ONCABG in cirrhotic patients with no concomitant surgical procedures were included. 829 unique abstracts were retrieved with title and abstract screening completed independently by two reviewers. Two case studies and six retrospective cohort studies were included. The largest study comprised more than 98% of the total population, showing some survival benefit for OPCAB over ONCABG. However, it was population-based and did not report the severity of liver. The remaining studies reported no clear difference in outcome between the two techniques. EXPERT OPINION : Surgical myocardial revascularisation carries high peri-operative risk in patients with liver cirrhosis irrespective of the surgical technique. There is a lack of evidence to suggest that avoiding CPB in these patients may be beneficial.
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Affiliation(s)
- Stephanie M Jiang
- Division of Cardiac Surgery, Queen's University, Kingston, ON, Canada
| | - Kiera Liblik
- Department of Cardiology, Queen's University, Kingston, ON, Canada
| | - Adrian Baranchuk
- Department of Cardiology, Queen's University, Kingston, ON, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Queen's University, Kingston, ON, Canada
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Jacob S, Nguyen JH, El-Sayed Ahmed MM, Makey IA, Haddad OK, Thomas M, Sareyyupoglu B, Pham SM, Landolfo KP. Combined cardiac surgery procedures and liver transplant: a single-center experience. Gen Thorac Cardiovasc Surg 2022; 70:714-720. [PMID: 35146597 DOI: 10.1007/s11748-022-01783-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/27/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Morbidity and mortality rates associated with liver transplant are high for patients with concomitant heart disease. Traditionally, such cases were considered contraindications for transplant. The objective of our study was to assess the outcome of combined surgical approaches. METHODS A prospectively maintained database was analyzed of patients undergoing cardiac surgery and liver transplant at our institution. Twelve identified patients underwent combined cardiac operation and liver transplant. A control group was created (n = 24) with the same selection criteria. RESULTS Median patient age was 64.94 years in the combined group vs 63.80 in the control, and in both groups, 58% were male. Left ventricular ejection fraction (0.60), body mass index (30.1), and median (range) score of the Model for End-stage Liver Disease (18 [9-33]) were the same in both groups. The cardiac operations combined with liver transplant were coronary artery bypass grafting, valve replacement procedures, and ascending thoracic aortic aneurysm repair. Piggyback liver transplant was performed for all patients. Survival periods of 1, 5, and 10 years for control vs combined cases were 90 vs 62%, 79 vs 55%, and 70 vs 45%, respectively (P = 0.03). CONCLUSION Concomitant cardiac procedure and liver transplant is a valid treatment option and should be considered with risk stratification criteria of the patient with end-stage liver disease and cardiac surgical pathologic characteristics.
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Affiliation(s)
- Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA.
| | - Justin H Nguyen
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Magdy M El-Sayed Ahmed
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Ian A Makey
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Osama K Haddad
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA.,Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Kevin P Landolfo
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA.,Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Zuñiga-Aguilar E, Ramírez-Fernández O. Fibrosis and hepatic regeneration mechanism. Transl Gastroenterol Hepatol 2022; 7:9. [PMID: 35243118 PMCID: PMC8826211 DOI: 10.21037/tgh.2020.02.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2023] Open
Abstract
Liver cirrhosis is the final stage of continuous hepatic inflammatory activity derived by viral, metabolic or autoimmune origin. In the last years, cirrhosis was considered a unique and static condition; recently was accepted some patients subgroups with different liver injury degrees that coexist under the same diagnosis, with implications about the natural disease history. The liver growth factor (LGF) is a potent in vivo and in vitro mitogenic agent and an inducer of hepatic regeneration (HR) through the hepatocytes DNA synthesis. The clinical implications of the LGF levels in cirrhosis, are not clear and even with having a fundamental role in the liver regeneration processes, the studies suggest that it could be a cirrhosis severity marker, in acute liver failure and in chronic hepatitis. Its role as predictor of mortality in fulminant hepatic insufficiency patients has been suggested. HR is one of the most enigmatic and fascinating biological phenomena. The rapid volume and liver function restoration after a major hepatectomy (>70%) or severe hepatocellular damage and its strict regulation of tissue damage response after the cessation, is an exclusive property of the liver. HR is the clinical applications fundament, such as extensive hepatic resections (>70% of the liver parenchyma), segmental transplantation or living donor transplantation, sequential hepatectomies, isolated portal embolization or associated with in situ hepatic transection, temporary artificial support in acute liver failure and the possible cell therapy clinical applications.
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Affiliation(s)
- Esmeralda Zuñiga-Aguilar
- Universidad Autonoma de Ciudad Juárez, Depto de Ingeniería Eléctrica y Computación, Ciudad Juárez, Chih., México
| | - Odin Ramírez-Fernández
- Tecnologico Nacional de Mexico, Depto. De Ciencias Basicas, Tlalnepantla de Baz, Mexico
- Facultad de Medicina, HIPAM, Universidad Nacional Autonoma de Mexico, Ciudad de México, Mexico
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Saito Y, Nakai T, Ikeya Y, Kogawa R, Otsuka N, Wakamatsu Y, Kurokawa S, Ohkubo K, Nagashima K, Okumura Y. Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy. ESC Heart Fail 2022; 9:1080-1089. [PMID: 34983080 PMCID: PMC8934924 DOI: 10.1002/ehf2.13776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 12/28/2022] Open
Abstract
Aims Multi‐organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End‐stage Liver Disease eXcluding International normalized ratio (MELD‐XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD‐XI score and the long‐term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated. Methods and results Clinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD‐XI score: first tertile (MELD‐XI = 9.44, n = 95), second tertile (9.44 < MELD‐XI < 13.4, n = 94), and third tertile (MELD‐XI ≥ 13.4, n = 94). The primary endpoint was all‐cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N‐terminal pro‐brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow‐up of 30 months (inter‐quartile range, 9–67), 105 patients (37.1%) died. Kaplan–Meier analysis revealed that patients with a higher MELD‐XI score had a greater risk of all‐cause mortality (log‐rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD‐XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00–1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01–1.09, P = 0.005, respectively). A higher MELD‐XI score was associated with a greater risk of all‐cause mortality than a lower MELD‐XI score regardless of whether a pacemaker or defibrillator was implanted (log‐rank test: P = 0.010 and P < 0.001, respectively). Conclusions Impaired hepatorenal function assessed by the MELD‐XI score was associated with older age, higher prevalence of multiple co‐morbidities, severity of HF, lower CRT response rates, and subsequent all‐cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD‐XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.
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Affiliation(s)
- Yuki Saito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yukitoshi Ikeya
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Naoto Otsuka
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6575310. [DOI: 10.1093/ejcts/ezac128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/31/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
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Ahmed T, Grigorian AY, Messerli AW. Management of Acute Coronary Syndrome in Patients with Liver Cirrhosis. Am J Cardiovasc Drugs 2022; 22:55-67. [PMID: 34050893 DOI: 10.1007/s40256-021-00478-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 12/12/2022]
Abstract
Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.
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Ahmed T, Misumida N, Grigorian A, Tarantini G, Messerli AW. Transcatheter interventions for valvular heart diseases in liver cirrhosis patients. Trends Cardiovasc Med 2021; 33:242-249. [PMID: 34974163 DOI: 10.1016/j.tcm.2021.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/27/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
There is an increasing prevalence of patients who have both liver cirrhosis (LC) and severe valvular heart disease. This combination typically poses prohibitive risk for liver transplantation. LC related malnourishment, hypoalbuminemia and hyperdynamic circulation places patients with severe LC at higher rates for significant bleeding and/or thrombosis, as well as infectious and renal complications, after either surgical or transcatheter valvular interventions. Although there remains scarce comparative evidence, the preponderance of data suggest that percutaneous strategies are preferred over surgical ones. A multidisciplinary team is ideal for identifying those patients with LC who would benefit from transcatheter valvular heart interventions.
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Affiliation(s)
- Taha Ahmed
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Naoki Misumida
- Department of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Alla Grigorian
- Department of Hepatology, University of Kentucky, Lexington, KY, USA
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Adrian W Messerli
- Department of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA.
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Lee DU, Han J, Fan GH, Hastie DJ, Kwon J, Lee KJ, Addonizio EA, Karagozian R. The clinical impact of chronic liver disease in patients undergoing transcatheter and surgical aortic valve replacement: Systematic analysis of the 2011-2017 US hospital database. Catheter Cardiovasc Interv 2021; 98:E1044-E1057. [PMID: 34562288 DOI: 10.1002/ccd.29952] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES In this study, we use a national database to evaluate post-transcatheter (TAVR)/surgical aortic valve replacement (SAVR) outcomes stratified using chronic liver disease (CLD). BACKGROUND In patients undergoing TAVR and SAVR, the surgical risks should be optimized; this includes evaluating hepatic diseases that may pose an operative risk. METHODS 2011-2017 National Inpatient Sample was used to select in-hospital TAVR and SAVR cases, which were stratified according to CLD (cirrhosis, hepatitis B/C, alcoholic/fatty/nonspecific liver disease). The cases-controls were matched using propensity score matching and compared with various endpoints. RESULT After matching for demographics and comorbidities, for TAVR, 606 and 1818 were with or without CLD; for SAVR, 1353 and 4059 were with and without CLD. In TAVR, there was no differences in mortality (2.81% vs. 2.75% OR 1.02 95% CI 0.58-1.78) or length of stay (6.29 vs. 6.44d p = 0.29), and CLD-present patients had marginally increased costs ($228,415 vs. $226,682 p = 0.048). There were no differences in complications. In multivariate, there was no difference in mortality (aOR 1.02 95% CI 0.58-1.79). In SAVR, CLD patients had higher mortality (7.98% vs. 3.23% OR 2.60 95% CI 2.00-3.38), length of stay (13.3 vs. 11.3 days p < 0.001), and costs ($273,487 vs. $238,097 p < 0.001). CLD patients also had increased respiratory failure (9.02% vs. 7.19% OR 1.28 95% CI 1.03-1.59) and bleeding (8.43% vs. 6.33% OR 1.36 95% CI 1.08-1.71). In multivariate, CLD had higher mortality (aOR 2.60 95% CI 2.00-3.38). CONCLUSION CLD is associated with higher mortality and complications in patients undergoing SAVR; however, no correlation was found in patients undergoing TAVR.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - John Han
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gregory Hongyuan Fan
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - David Jeffrey Hastie
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jean Kwon
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ki Jung Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Elyse Ann Addonizio
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Raffi Karagozian
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
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Xu F, Zhang L, Wang Z, Han D, Li C, Zheng S, Yin H, Lyu J. A New Scoring System for Predicting In-hospital Death in Patients Having Liver Cirrhosis With Esophageal Varices. Front Med (Lausanne) 2021; 8:678646. [PMID: 34708050 PMCID: PMC8542681 DOI: 10.3389/fmed.2021.678646] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/15/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction: Liver cirrhosis is caused by the development of various acute and chronic liver diseases. Esophageal varices is a common and serious complication of liver cirrhosis during decompensation. Despite the development of various treatments, the prognosis for liver cirrhosis with esophageal varices (LCEV) remains poor. We aimed to establish and validate a nomogram for predicting in-hospital death in LCEV patients. Methods: Data on LCEV patients were extracted from the Medical Information Mart for Intensive Care III and IV (MIMIC-III and MIMIC-IV) database. The patients from MIMIC-III were randomly divided into training and validation cohorts. Training cohort was used for establishing the model, validation and MIMIC-IV cohorts were used for validation. The independent prognostic factors for LCEV patients were determined using the least absolute shrinkage and selection operator (LASSO) method and forward stepwise logistic regression. We then constructed a nomogram to predict the in-hospital death of LCEV patients. Multiple indicators were used to validate the nomogram, including the area under the receiver operating characteristic curve (AUC), calibration curve, Hosmer-Lemeshow test, integrated discrimination improvement (IDI), net reclassification index (NRI), and decision curve analysis (DCA). Results: Nine independent prognostic factors were identified by using LASSO and stepwise regressions: age, Elixhauser score, anion gap, sodium, albumin, bilirubin, international normalized ratio, vasopressor use, and bleeding. The nomogram was then constructed and validated. The AUC value of the nomogram was 0.867 (95% CI = 0.832–0.904) in the training cohort, 0.846 (95% CI = 0.790–0.896) in the validation cohort and 0.840 (95% CI = 0.807–0.872) in the MIMIC-IV cohort. High AUC values indicated the good discriminative ability of the nomogram, while the calibration curves and the Hosmer-Lemeshow test results demonstrated that the nomogram was well-calibrated. Improvements in NRI and IDI values suggested that our nomogram was superior to MELD-Na, CAGIB, and OASIS scoring system. DCA curves indicated that the nomogram had good value in clinical applications. Conclusion: We have established the first prognostic nomogram for predicting the in-hospital death of LCEV patients. The nomogram is easy to use, performs well, and can be used to guide clinical practice, but further external prospective validation is still required.
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Affiliation(s)
- Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Luming Zhang
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zichen Wang
- Department of Public Health, University of California, Irvine, Irvine, CA, United States
| | - Didi Han
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Chengzhuo Li
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Shuai Zheng
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Haiyan Yin
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
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Amdani S, Boyle GJ, Cantor RS, Conway J, Godown J, Kirklin JK, Koehl D, Lal AK, Law Y, Lorts A, Rosenthal DN. Significance of pre and post-implant MELD-XI score on survival in children undergoing VAD implantation. J Heart Lung Transplant 2021; 40:1614-1624. [PMID: 34598872 DOI: 10.1016/j.healun.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Derangements in liver and renal function often accompany end-stage heart failure. We sought to assess the utility of an objective risk assessment tool, the Model for End-stage Liver Disease eXcluding INR (MELD-XI), to identify pediatric patients at increased risk for adverse outcomes post-ventricular assist device (VAD) implantation. METHODS The Pedimacs database was queried for all pediatric patients who underwent VAD implantation from September 19, 2012 to December 31, 2019. Pre-implant and early (1-week) post-implant MELD-XI scores were used to stratify patients into low, intermediate and high score cohorts. Comparison of pre-implant characteristics and post-implant outcomes were conducted across groups. Multiphase parametric hazard modeling was utilized to identify independent predictors of post-implant mortality. RESULTS A total of 742 patients had a calculable MELD-XI score pre-implant. When stratified by MELD-XI scores pre-implant, patients in the high MELD-XI score cohort (score >13.6) had inferior survival and increased bleeding, renal dysfunction and respiratory failure post-implant compared to intermediate and low score cohorts. Risk factors for mortality post-VAD implantation were: increasing MELD-XI scores (HR 1.1 per 1 unit rise), Pedimacs profile 1 (HR 1.6), congenital heart disease (HR 2.3) and being on a percutaneous VAD (HR 2.7). Importantly, MELD-XI score was a better predictor of post-VAD implant mortality than bilirubin or creatinine alone, neither of which were significant in the final model. Patients with increasing or continued high MELD-XI scores early post-implant had the worst survival. CONCLUSION The MELD-XI is an easily calculated score that serves as a promising risk assessment tool in identifying children at risk for poor outcomes post VAD implantation.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Gerard J Boyle
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer Conway
- Department of Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashwin K Lal
- Division of Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Yuk Law
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Angela Lorts
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - David N Rosenthal
- Department of Cardiology, Stanford University, Palo Alto, California
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Naghashzadeh F, Noorali S, Hosseini-Baharanchi FS, Shafaghi S, Sharif-Kashani B, Ahmadi ZH, Keshmiri MS. Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients. EXP CLIN TRANSPLANT 2021; 19:963-969. [PMID: 34545779 DOI: 10.6002/ect.2020.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant. MATERIALS AND METHODS Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease. RESULTS Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01). CONCLUSIONS Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.
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Affiliation(s)
- Farah Naghashzadeh
- From the Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Lee PJ, Papachristou GI. Early Prediction of Severity in Acute Pancreatitis. CLINICAL PANCREATOLOGY FOR PRACTISING GASTROENTEROLOGISTS AND SURGEONS 2021:31-39. [DOI: 10.1002/9781119570097.ch4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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39
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The imperative for an updated cirrhosis surgical risk score. Ann Hepatol 2021; 19:341-343. [PMID: 32474073 DOI: 10.1016/j.aohep.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
The burden of cirrhosis is increasing, as is the need for surgeries in patients with cirrhosis. These patients have increased surgical risk relative to non-cirrhotic patients. Unfortunately, currently available cirrhosis surgical risk prediction tools are non-specific, poorly calibrated, limited in scope, and/or outdated. The Mayo score is the only dedicated tool to provide discrete post-operative mortality predictions for patients with cirrhosis, however it has several limitations. First, its single-center nature does not reflect institution-specific practices that may impact surgical risk. Second, it pre-dates major surgical changes that have changed the landscape of patient selection and surgical risk. Third, it has been shown to overestimate risk in external validation. Finally, and perhaps most importantly, the score does not account for differences in risk based on surgery type. The clinical consequences of inaccurate prediction and risk overestimation are significant, as patients with otherwise acceptable risk may be denied elective surgical procedures, thereby increasing their future need for higher-risk emergent procedures. Confident evaluation of the risks and benefits of surgery in this growing population requires an updated, generalizable, and accurate cirrhosis surgical risk calculator that incorporates the type of surgery under consideration.
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40
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Juneja R, Kumar A, Ranjan R, Hemantlal PM, Mehta Y, Wasir H, Vohra V, Trehan N. Combined off pump coronary artery bypass graft and liver transplant. Ann Card Anaesth 2021; 24:197-202. [PMID: 33884976 PMCID: PMC8253011 DOI: 10.4103/aca.aca_194_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/25/2020] [Accepted: 05/30/2020] [Indexed: 11/27/2022] Open
Abstract
Background Prospective recipients of liver transplant (LT) have a high prevalence rate of coronary artery disease (CAD) requiring revascularization. In patients of Child Turcot Pugh Class B and C performing LT prior to cardiac revascularization on cardiopulmonary bypass leads to a high risk of major adverse cardiovascular events (MACE). Whereas, isolated cardiac surgery prior to LT has perioperative risk of coagulopathy, sepsis, and hepatic decompensation. We present four cases of end stage liver disease who underwent concomitant living donor liver transplant (LDLT) with off pump coronary artery bypass graft (OPCAB) in an effort to decrease the morbidity and mortality. Methods The cases were performed in a tertiary care centre over two years. Four patients scheduled for LDLT, who were diagnosed with significant CAD, underwent single sitting OPCAB and LDLT. Cardiac surgery was performed first and once patient was stable, it was followed by LDLT. The morbidity parameters in terms of duration of intubation, blood transfusion, hospital stay, ICU stay, requirement of dialysis, atrial fibrillation and sepsis was compared with similar studies. Results The blood transfusion requirement (median 8 units PRBC), incidence of atrial fibrillation (25%), sepsis (25%), and renal dysfunction (0%) was less than the combined surgery conducted on cardiopulmonary bypass. The rate of median intubation time, length of ICU stay, hospital stay, and one year mortality rate was comparable with other studies. Conclusions Morbidity with combined OPCAB and LDLT is less than combined on pump coronary artery bypass surgery with LDLT. Combined CABG with LDLT may be performed with acceptable outcomes in CTP class B and C cirrhosis.
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Affiliation(s)
- Rajiv Juneja
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Ajay Kumar
- Department of Anaesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rajeev Ranjan
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - P M Hemantlal
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Yatin Mehta
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Harpreet Wasir
- Medanta Heart Institute, Medanta the Medicity, Rishikesh, Uttarakhand, India
| | - Vijay Vohra
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Naresh Trehan
- Medanta Heart Institute, Medanta the Medicity, Rishikesh, Uttarakhand, India
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41
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Baysal A, Sagiroglu G, Dogukan M, Ozkaynak I. Investigation of Risk Factors Related to the Development of Hepatic Dysfunction in Patients with a Low and Moderate Cardiac Risk During Open-Heart Surgeries. Braz J Cardiovasc Surg 2021; 36:219-228. [PMID: 34048203 PMCID: PMC8163266 DOI: 10.21470/1678-9741-2019-0427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective To determine the possible risk factors associated with hepatic dysfunction during open-heart surgeries. Methods After excluding 71 patients, 307 patients with possible low and moderate cardiac risk who underwent either coronary artery bypass graft surgery (CABG) (n=176) or valve repair surgery (mitral valve, mitral and aortic valves and/or tricuspid valve) (n=131) were investigated prospectively during a 6-month period. Hyperbilirubinemia is defined as an occurrence of a plasma total bilirubin concentration >34 µmol/L (2 mg/dL) in any measurement during the postoperative period; the patients were divided into groups with or without postoperative hyperbilirubinemia. The collected parameters were: alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), total bilirubin (TBil), gamma-glutamyl transpeptidase (GGT) and albumin. The parameters were collected preoperatively and postoperatively on days 1, 3 and 7. Preoperative, intraoperative, and postoperative risk factors were investigated. Logistic regression analysis was performed to identify the risk factors for postoperative hyperbilirubinemia. Results Postoperative hyperbilirubinemia was observed in 7 of 176 patients (4%) who underwent CABG, and in 11 of 131 patients (8.4%) who underwent valve replacement surgeries. Independent risk factors for early postoperative hyperbilirubinemia were found as: ejection fraction (EF), aortic cross-clamp (ACC) time, intensive care unit stay and extubation time (P<0.001). In comparison to CABG procedures, postoperative hyperbilirubinemia was observed more frequently in patients undergoing valve surgeries (P=0.027). Conclusion Low EF and prolonged ACC time are significant independent risk factors for early postoperative hyperbilirubinemia during open-heart surgeries with cardiopulmonary bypass. Valve surgeries show a higher incidence of hyperbilirubinemia in comparison to CABG.
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Affiliation(s)
- Ayse Baysal
- Pendik Bolge Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Gonul Sagiroglu
- Department of Anaesthesiology and Reanimation, Trakya University Medical Faculty, Edirne, Turkey
| | - Mevlut Dogukan
- Department of Anaesthesiology and Reanimation, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Ismail Ozkaynak
- Surreyyapasa Pulmonary Diseases and Thoracic Surgery Research and Training Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey
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Hong Y, Dufendach K, Wang Y, Thoma F, Kilic A. Impact of hepatic steatosis on outcomes after left ventricular assist device implantation. J Card Surg 2021; 36:2277-2283. [PMID: 33783048 DOI: 10.1111/jocs.15536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/07/2021] [Accepted: 03/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This single-center, retrospective study evaluates the impact of hepatic steatosis on outcomes after continuous-flow left ventricular assist device (LVAD) implantation. METHODS Adults undergoing LVAD implantation between 2004 and 2018 with a preoperative noncontrast-enhanced chest and abdominal computed tomography scan were included in the study. Patients were stratified as with and without radiographic signs of hepatic steatosis. The primary outcome was survival, and secondary outcomes included rates of postimplant adverse events. RESULTS A total of 203 patients were included in the study. 27.6% (n = 56) had radiographic signs of hepatic steatosis. Hepatic steatosis group had a higher body mass index (30.1 vs. 27.0, p < .01), model for end-stage liver disease excluding international normalized ratio score (16.8 vs. 15.1, p = .05), and incidence of diabetes (53.6% vs. 35.4%, p = .02). The rates of postimplant adverse events, including bleeding, infection, reoperation, renal failure, hepatic dysfunction, stroke, and right ventricular failure, were similar between the groups (all, p > .05). Unadjusted survival was comparable between the groups at 30-days, 90-days, 1-year, and 2-year following LVAD implantation (all, p > .05). In addition, hepatic steatosis did not impact risk-adjusted overall mortality when modeled as a categorical variable (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.46-1.13; p = .15). CONCLUSIONS This study demonstrates that the presence of preoperative hepatic steatosis on imaging is not predictive of increased morbidity or mortality following LVAD implantation. Despite the association with obesity, metabolic diseases, and heart failure, hepatic steatosis on imaging appears to have a limited role in patient selection or prognostication in LVAD patients.
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Affiliation(s)
- Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Keith Dufendach
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Wang C, Ding ZW, Zheng CG, Wang S, Li ZH, Zhang ZM, Pan J, Wang J, Yang C. COCH predicts survival and adjuvant TACE response in patients with HCC. Oncol Lett 2021; 21:275. [PMID: 33732351 PMCID: PMC7905559 DOI: 10.3892/ol.2021.12536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
The aim of the present study was to measure the expression of Cochlin (COCH) and analyze its association with survival, recurrence and the benefits from adjuvant transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) following hepatectomy. Patients with high COCH expression levels had a poorer prognosis in terms of overall and disease-free survival rate compared with those with low COCH expression levels. Further analysis revealed that patients with low COCH expression who received TACE experienced markedly lower early recurrence rates compared with those who did not receive TACE. However, patients with high COCH expression with and without adjuvant TACE after resection experienced no difference in disease recurrence rates. The expression of COCH was found to be associated with hepatitis B virus infection, portal vein tumor thrombosis and Barcelona Clinic Liver Cancer stage in HCC. Therefore, the findings of the present study indicated that clinical detection of COCH expression may help estimate the prognosis of patients with HCC, as well as determine whether to administer TACE after surgery to prevent recurrence.
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Affiliation(s)
- Chen Wang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, P.R. China.,Department of Pediatric Surgery, Hangzhou Children's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Zhi-Wen Ding
- Department of Hepatobiliary Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 201805, P.R. China
| | - Cheng-Gang Zheng
- Department of Hyperbaric Medicine, Changhai Hospital, Naval Medical University, Shanghai 200433, P.R. China
| | - Siyuan Wang
- Suzhou Institute of Drug Control, Suzhou, Jiangsu 215031, P.R. China
| | - Zhi-Heng Li
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, P.R. China
| | - Zi-Mu Zhang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, P.R. China
| | - Jian Pan
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, P.R. China
| | - Jian Wang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, P.R. China
| | - Chun Yang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu 215025, P.R. China
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Kuang J, Yang J, Wang Q, Yu C, Li Y, Fan R. A preoperative mortality risk assessment model for Stanford type A acute aortic dissection. BMC Cardiovasc Disord 2020; 20:508. [PMID: 33272195 PMCID: PMC7712615 DOI: 10.1186/s12872-020-01802-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/26/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute aortic dissection type A is a life-threatening disease required emergency surgery during acute phase. Different clinical manifestations, laboratory tests, and imaging features of patients with acute aortic dissection type A are the risk factors of preoperative mortality. This study aims to establish a simple and effective preoperative mortality risk assessment model for patients with acute aortic dissection type A. METHODS A total of 673 Chinese patients with acute aortic dissection type A who were admitted to our hospital were retrospectively included. All patients were unable to receive surgically treatment within 3 days from the onset of disease. The patients included were divided into the survivor and deceased groups, and the endpoint event was preoperative death. Multivariable analysis was used to investigate predictors of preoperative mortality and to develop a prediction model. RESULTS Among the 673 patients, 527 patients survived (78.31%) and 146 patients died (21.69%). The developmental dataset had 505 patients, calibration by Hosmer Lemeshow was significant (χ2 = 3.260, df = 8, P = 0.917) and discrimination by area under ROC curve was 0.8448 (95% CI 0.8007-0.8888). The validation dataset had 168 patients, calibration was significant (χ2 = 5.500, df = 8, P = 0.703) and the area under the ROC curve was 0.8086 (95% CI 0.7291-0.8881). The following independent variables increased preoperative mortality: age (OR = 1.008, P = 0.510), abrupt chest pain (OR = 3.534, P < 0.001), lactic in arterial blood gas ≥ 3 mmol/L (OR = 3.636, P < 0.001), inotropic support (OR = 8.615, P < 0.001), electrocardiographic myocardial ischemia (OR = 3.300, P = 0.001), innominate artery involvement (OR = 1.625, P = 0.104), right common carotid artery involvement (OR = 3.487, P = 0.001), superior mesenteric artery involvement (OR = 2.651, P = 0.001), false lumen / true lumen of ascending aorta ≥ 0.75 (OR = 2.221, P = 0.007). Our data suggest that a simple and effective preoperative death risk assessment model has been established. CONCLUSIONS Using a simple and effective risk assessment model can help clinicians quickly identify high-risk patients and make appropriate medical decisions.
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Affiliation(s)
- Juntao Kuang
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515 China
| | - Jue Yang
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
| | - Qiuji Wang
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515 China
| | - Changjiang Yu
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
| | - Ying Li
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
- Department of Cardiovascular Surgery, Guangdong Provincial People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, 510030 China
| | - Ruixin Fan
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Adv Anesth 2020; 38:251-267. [PMID: 34106838 DOI: 10.1016/j.aan.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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Peeraphatdit TB, Nkomo VT, Naksuk N, Simonetto DA, Thakral N, Spears GM, Harmsen WS, Shah VH, Greason KL, Kamath PS. Long-Term Outcomes After Transcatheter and Surgical Aortic Valve Replacement in Patients With Cirrhosis: A Guide for the Hepatologist. Hepatology 2020; 72:1735-1746. [PMID: 32080875 DOI: 10.1002/hep.31193] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 01/28/2020] [Accepted: 02/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Hepatologists often determine whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is preferred for patients with cirrhosis and severe aortic stenosis. The goal of this cohort study is to compare outcomes following TAVR and SAVR in patients with cirrhosis to inform the preferred intervention. APPROACH AND RESULTS Prospectively collected data on 105 consecutive patients with cirrhosis and aortic stenosis who underwent TAVR (n = 55) or SAVR (n = 50) between 2008 and 2016 were reviewed retrospectively. Two control groups were included: 2,680 patients without cirrhosis undergoing TAVR and SAVR and 17 patients with cirrhosis who received medical therapy alone. Among the 105 patients with cirrhosis, the median Society of Thoracic Surgeons score was 3.8% (1.5, 6.9), and the median Model for End-Stage Liver Disease (MELD) score was 11.6 (9.4, 14.0). The TAVR group had similar in-hospital (1.8% vs. 2.0%) and 30-day mortality (3.6% vs. 4.2%) as the SAVR group. During the median follow-up of 3.8 years (95% confidence interval, 3.0-6.9), there were 63 (60%) deaths. MELD score (adjusted hazard ratio, 1.13; 95% confidence interval, 1.05-1.21; P = 0.002) was an independent predictor of long-term survival. In the subgroup of patients with MELD score <12, the TAVR group had reduced survival compared with the SAVR group (median survival of 2.8 vs. 4.4 years; P = 0.047). However, in those with MELD score ≥12, survival after TAVR, SAVR, and medical therapy was similar (1.3 vs. 2.1 vs. 1.6 years, respectively; P = 0.53). CONCLUSION In select patients with cirrhosis, both TAVR and SAVR have acceptable and comparable short-term outcomes. MELD score, but not Society of Thoracic Surgeons score, independently predicts long-term survival after TAVR and SAVR. For patients with MELD score <12, SAVR is a preferred procedure; however, neither procedure appears superior to medical therapy in patients with MELD score ≥12.
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Affiliation(s)
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Niyada Naksuk
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Division of Cardiology, University of Illinois at Chicago, Chicago, IL
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Nimish Thakral
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Grant M Spears
- Division of Biostatistics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William S Harmsen
- Division of Biostatistics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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Chaubey S, Hussain A, Zakai SB, Butt S, Punjabi P, Desai J. Concomitant cardiac surgery and liver transplantation: an alternative approach in patients with end stage liver failure? Perfusion 2020; 36:737-744. [PMID: 33094695 DOI: 10.1177/0267659120966549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The results of cardiac surgery in patients with end-stage-liver-disease (ESLD) are poor. Concomitant cardiac surgery and orthotopic liver transplantation (OLT) may be an alternative treatment strategy in these patients. METHODS Between 2001 and 2018, eight patients underwent concomitant cardiac surgery and OLT (Conc_OLT) in our institution. We analyzed their preoperative, intraoperative and postoperative data and compared them to seven high risk patients with ESLD who underwent isolated cardiac surgery (Iso_Surg). RESULTS The two groups were not significantly different in terms of gender and age (Conc_OLT: 5 males, 55 ± 15 years, Iso_Surg: 4 males, 60 ± 10 years). Causes for ESLD were primary biliary cirrhosis (Conc_OLT = 1, Iso_Surg = 1), alcoholism (Conc_OLT = 2, Iso_Surg = 2), viral hepatitis (Conc_OLT = 2, Iso_Surg = 2), cryptogenic (Conc_OLT = 2, Iso_Surg = 1), ischemic (Conc_OLT = 1) and hepatocellular carcinoma (Iso_Surg = 1). Model for End-stage-Liver-Disease (MELD) Score (Conc_OLT = 14, Iso_Surg = 13) and Child-Pugh Score (Conc_OLT = 9.5, Iso_Surg = 8) were not significantly different between the two groups. Median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 9.5% (Conc_OLT) and 7.1% (Iso_Surg). Cardiac procedures undertaken were aortic valve replacement (Conc_OLT = 6, Iso_Surg = 3), coronary bypass grafting (Conc_OLT = 1,Iso_Surg = 2), tricuspid valve repair (Conc_OLT = 1), combined aortic and mitral valve replacement (Iso_Surg = 1) and excision of atrial myxoma (Iso_Surg = 1). Median length of in-hospital-stay was longer in the Conc_OLT group (73 vs. 42 days; p = 0.11). At 3 months, in-hospital mortality was 25% in the Conc_OLT group (n = 2) and lower compared to 71% observed in the Iso_Surg group (n = 5, p = 0.13). CONCLUSION Concomitant cardiac surgery and OLT is a promising alternative compared to isolated cardiac surgery in high risk patients with ESLD. Given the high operative mortality of cardiac surgery in patients with ESLD, the complex peri-operative management of these patients should be performed in an interdisciplinary team with an expert team of liver specialists involved.
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Affiliation(s)
- Sanjay Chaubey
- Department of Cardiothoracic Surgery, Hammermsmith Hospital, London, UK
| | - Azhar Hussain
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Saad Badar Zakai
- Department of Cardiothoracic Surgery, National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Salman Butt
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Hammermsmith Hospital, London, UK
| | - Jatin Desai
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
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Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease-A Retrospective Analysis of 76 Cases in a Tertiary Center. BIOLOGY 2020; 9:biology9110349. [PMID: 33105795 PMCID: PMC7690599 DOI: 10.3390/biology9110349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/18/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
Simple Summary It is well known that the incidence of liver cirrhosis is increasing and it negatively affects outcome after surgery. While there are several studies investigating the influence of liver cirrhosis on colorectal, hepatobiliary, or hernia surgery, data about its impact on small bowel surgery are completely lacking. Therefore, a retrospective analysis over a period of 17 years was performed including 76 patients with liver cirrhosis and small bowel surgery. Postsurgical complications were analyzed, and 38 parameters as possible predictive factors for a worse outcome were investigated. We observed postsurgical complications in over 90% of the patients; in over 50%, the complications were classified as severe. When subdividing postoperative complications, bleeding, respiratory problems, wound healing disorders and anastomotic leakage, hydropic decompensation, and renal failure were most common. The most important predictive factors for those complications after uni- and multivariate analysis were portal hypertension, poor liver function, emergency or additional surgery, ascites, and high ASA score. We, therefore, recommend treatment of portal hypertension before small bowel surgery to avoid extension of the operation to other organs than the small bowel and in case of ascites to evaluate the creation of an anastomosis stoma instead of an unprotected anastomosis to prevent leakages. Abstract (1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.
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Schizas D, Peppas S, Giannopoulos S, Lagopoulou V, Mylonas KS, Giannopoulos S, Moris D, Felekouras E, Toutouzas K. The Impact of Cirrhosis on Pancreatic Cancer Surgery: A Systematic Review and Meta-Analysis. World J Surg 2020; 45:562-570. [PMID: 33073316 DOI: 10.1007/s00268-020-05821-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cirrhosis has been considered a contraindication to major abdominal surgeries, due to increased risk for postoperative morbidity and mortality. The aim of this study was to assess the safety of pancreatectomy in cirrhotic versus non-cirrhotic patients. METHODS The present systematic review and meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All meta-analyses were performed using the random effects model. RESULTS Eight studies were eventually included, enrolling 1229 patients (cirrhotics: 722; and Child-Pugh A: 593; Child-Pugh B/C: 129) who underwent surgery for pancreatic cancer. The overall postoperative morbidity rate was 66% (51%-80%). Infections (26%) and ascites formation/worsening (23%) were the most common postoperative complications, followed by anastomotic leak/fistula (17%). Non-cirrhotic patients were less likely to suffer from anastomotic leak/fistula (OR: 0.39; 95% CI: 0.23-0.65) and infections (OR: 0.41; 95% CI: 0.25-0.67). Postoperative mortality rate was statistically significantly lower in non-cirrhotic versus cirrhotic patients (OR: 0.18; 95% CI:0.18-0.39). The odds ratios of 1 year (OR: 0.62; 95% CI: 0.30-1.30), 2 year (OR: 0.67; 95% CI: 0.25-1.83) and 3 year all-cause mortality (OR: 0.32; 95% CI: 20.03-2.99) were not significantly different between cirrhotic versus non-cirrhotic patients. CONCLUSION This study demonstrated that non-cirrhotic patients were less likely to undergo any type of re-intervention and had statistically significant lower postoperative mortality rates compared to patients with cirrhosis.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Spyridon Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens, Greece
| | | | - Vasiliki Lagopoulou
- Department of Surgery, 251 VA and Hellenic Air Force Hospital, Athens, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Giannopoulos
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Evangelos Felekouras
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- First Propedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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50
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Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions. Clin Gastroenterol Hepatol 2020; 18:2398-2414.e3. [PMID: 31376494 PMCID: PMC6994232 DOI: 10.1016/j.cgh.2019.07.051] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures. METHODS We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review. RESULTS Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate. CONCLUSIONS Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.
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Affiliation(s)
- Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington.
| | - Kay M Johnson
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul B Cornia
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kamal Itani
- Boston VA Health Care System and Boston University, Boston, Massachusetts
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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