Parameter changes and influencing factors in sixty patients with interventional surgery for liver cancer diagnoses

Abstract

BACKGROUND

The development of hepatocellular carcinoma (HCC) is influenced by multiple factors. Interventional therapy offers an effective treatment option for patients with unresectable intermediate-to-advanced HCC. Interventional therapy can induce electrocardiographic (ECG) abnormalities that may be associated with liver dysfunction, electrolyte disorders, and cardiac injury.

AIM

To explore the ECG alterations and determinants following interventional therapy in patients with HCC.

METHODS

Sixty patients undergoing interventional treatment for liver cancer were selected as study participants. According to the results of the dynamic ECG examination 1 day after surgery, the patients were divided into an abnormal group (n = 21) and a nonabnormal group (n = 39). With the help of dynamic ECG examination, the ECG parameters were compared and the baseline data of patients was recorded in the two groups.

RESULTS

The 24 hours QT interval variability, 24 hours normal atrial polarization to ventricular polarization (R-R) interval (standard deviation), 24 hours consecutive 5 minutes normal R-R interval, and 24 hours continuous 5 minutes normal R-R interval (standard deviation mean) were lower than patients in the nonabnormal group (P < 0.05). The logistic analysis showed that age > 60 years, liver function grade B, and postoperative body temperature 38 °C were risk factors for abnormal dynamic electrocardiogram in patients with liver cancer intervention (P < 0.05).

CONCLUSION

Interventional therapy for HCC can lead to ECG abnormalities, underscoring the clinical need for enhanced cardiac monitoring to mitigate myocardial complications.

Key Words: Liver cancer; Interventional therapy; Holter electrocardiogram; Perioperative; Influencing factors

Core Tip: The Electrocardiographic abnormalities of liver cancer patients should be clarified as soon as possible, and targeted intervention measures are needed for the risk factors affecting their electrocardiographic abnormalities, especially for those undergoing interventional therapy.

INTRODUCTION

The complex formation and progression of liver cancer is affected by the combination of many factors, including genetic variation, environmental factors and the transformation of patients’ living habits[1]. Liver cancer interventional treatment refers to arterial intubation, with chemotherapy drugs, iodinated oil emulsion, or drug-loaded microspheres administered into the tumor-feeding artery for chemotherapy and embolization, which can significantly improve tumor local drug concentration, thus improving the treatment effect[2]. Also, because it is a local treatment, it can effectively reduce the systemic side effects of chemotherapy drugs. As a local treatment method for liver cancer, interventional therapy has the advantages of a definite curative effect, less trauma, quick recovery, and reproducibility, and is widely used in clinical practice. Although liver cancer interventions have achieved remarkable results in clinical practice, some patients show abnormal electrocardiograms (ECGs) after surgery, as some researchers have pointed out[3]. Patients with primary liver cancer have a low survival rate, and the correlation between abnormal ECG results and patient prognosis is significant. However, there are limited data on the factors affecting ECG abnormalities in patients. In this study, the influencing factors of 60 patients admitted to our hospital were analyzed to determine the risk factors for abnormalities.

MATERIALS AND METHODS

General data

Sixty patients with liver cancer admitted from April 2022 to April 2024 were selected for observation, including 34 men and 26 women, aged from 38 years to 72 years (average, 55.00 ± 11.28). The diagnostic criteria were those defined in the Guidelines for Diagnosis and Treatment of Primary Liver Cancer (2022 edition)[4]. The inclusion criteria were as follows: (1) Ability to undergo interventional surgery for liver cancer; (2) Fasting before surgery; and (3) Informed consent from patients and family members. The exclusion criteria were as follows: (1) Severe liver dysfunction, Child-Pugh grade C; (2) Severe coagulation dysfunction that could not be corrected; (3) Fewer collateral circulatory vessels; (4) Mental disorders; (5) Extensive distant tumor metastasis with an estimated survival of < 3 months; and (6) Severe infection.

Methods

Sampling method: Using multistage random sampling, 66 patients undergoing liver cancer interventional treatment between April 2022 and April 2024 were selected, and a questionnaire survey was conducted. Sixty-six questionnaires were sent and 64 questionnaires were returned, for a return rate of 96.97%; 60 valid questionnaires were obtained, and the effectiveness rate was 90.91%.

Investigation methods for basic data: This study used a face-to-face questionnaire or had medical staff fill in the basic data, including radio, multiple-choice, and judgment; basic information on patients with liver cancer (age, education level, sex, course of disease, etc.); condition (liver function grade, tumor diameter, and drug use); and postoperative signs (postoperative temperature, postoperative vomiting, and 3 days postoperative blood potassium level).

Detection of ECG-related parameters in patients with liver cancer intervention: On the first day after the operation, a Holter monitor (Boying B19800) was used from 8 am to 8 am on the same day to analyze and measure the ECG-related parameters.

Quality controls: To maintain strict quality control, investigators first underwent professional training in examination, use of the questionnaire, and collecting face-to-face information. The investigation team represented different departments, composed of one quality controller and one investigator. After the completion of the survey, an audit was conducted for logical problems, writing errors, etc., and problems were corrected. After all surveys, the questionnaires were reviewed again, screening out the invalid questionnaires. After the pre-experiment, the Cronbach’s α coefficient of the general data of this survey was 0.84, 0.61-0.83 for each dimension; retest reliability was 0.82, 0.70-0.86 for each dimension; and content validity was 0.92.

Observational indicators

The ECG-related parameters were compared between the two patient groups. According to the results obtained one day after surgery, 60 patients were divided into two groups: An abnormal group (n = 21) and a nonabnormal group (n = 39). Univariate analysis was conducted of ECG abnormalities in patients, followed by multivariate analysis of ECG abnormalities in patients. The variability of the QT interval over a 24-hour period [24 hours QT interval variability (QTV)] reflects the variability in the cardiac repolarization process, and is valuable for assessing cardiac electrical stability and predicting cardiac events.

The standard deviation of all normal sinus beat intervals [normal-to-normal intervals; 24 hours normal atrial polarization to ventricular polarization (R-R) interval (standard deviation) (SDNN)] over a 24-hour period is a time-domain measure of heart rate variability (HRV) that reflects overall HRV and is important for assessing cardiac autonomic function. “SDANN index (24 hours consecutive 5 minutes normal R-R interval)” denotes the average of the standard deviations of normal sinus R-R intervals over every 5-minute epoch within a 24-hour period, which is another time-domain measure used to assess HRV. SDNN index may be a misnomer for the SDNN or an alternative expression. Typically, SDNN refers to the standard deviation of all sinus beat R-R intervals employed for HRV assessment of HRV.

Statistical analysis

All the data of this study were entered into SPSS version 25.0 for analysis. Count data was expressed as [n (%)], χ² test, and measurement data with a normal distribution was expressed as mean ± SD, t-test. A logistic multiple regression model was used to analyze risk factors, with P < 0.05 representing statistical significance.

RESULTS

The ECG-related parameters were compared between the two patient groups. The 24 hours QTV, SDNN, SDANN-index, and SDNN-index were lower than those of nonabnormal patients (P < 0.05), as shown in Table 1. Univariate analysis of ECG abnormalities revealed that age, Child-Pugh grade of liver function, and postoperative body temperature were the factors affecting ECG abnormalities in patients undergoing hepatocellular carcinoma (HCC) intervention, with statistically significant differences (P < 0.05), as shown in Table 2. Multivariate analysis of ECG abnormalities in patients revealed that age > 60 years, Child-Pugh grade B of liver function, and postoperative body temperature 38 °C were risk factors (P < 0.05), as shown in Tables 3 and 4.

Table 1 Comparison of electrocardiographic-related parameters, mean ± SD.

Group	Case	24 hours QTV	SDNN	SDANN-index	SDNN-index
Abnormal group	21	19.44 ± 3.12	75.88 ± 11.85	66.46 ± 9.44	28.11 ± 5.44
Non-abnormal group	39	22.89 ± 5.44	84.34 ± 12.44	72.46 ± 11.12	35.11 ± 7.44
t	-	3.120	2.592	2.204	4.162
P value	-	0.003	0.012	0.032	< 0.001

QTV: Interval variability; SDNN: 24 hours normal atrial polarization to ventricular polarization (R-R) interval (standard deviation); SDANN-index: 24 hours consecutive 5 minutes normal R-R interval; SDNN-index: 24 hours continuous 5 minutes normal R-R interval (standard deviation mean).

Table 2 Univariate analysis of electrocardiographic abnormalities in patients, n (%).

Project	Abnormal group (n = 21)	Non-abnormal group (n = 39)	t/χ2	P value
Sex
Male	12 (57.14)	22 (56.41)	0.003	0.956
Female	9 (42.86)	17 (43.59)	-	-
Age
≤ 60 years	6 (28.57)	28 (71.79)	10.385	0.001
> 60 years	15 (71.43)	11 (28.21)	-	-
Tumor diameter
< 10 cm	19 (90.48)	34 (87.18)	0.002	0.966
≥ 10 cm	2 (9.52)	5 (12.82)	-	-
Course of disease, mean ± SD	4.84 ± 0.34	5.02 ± 0.41	0.303	0.763
Liver function Child-Pugh grade
A	6 (28.57)	26 (66.67)	7.959	0.005
B	15 (71.43)	13 (33.33)	-	-
Postoperative vomiting
Yes	11 (52.38)	20 (51.28)	0.007	0.935
No	10 (47.62)	19 (48.72)	-	-
Postoperative body temperature
< 38 °C	7 (33.33)	28 (71.79)	8.308	0.004
≥ 38 °C	14 (66.67)	11 (28.21)	-	-
Postblood potassium at 3 days
< 6 mmol/L	18 (85.71)	28 (71.79)	0.803	0.370
≥ 6 mmol/L	3 (14.29)	11 (28.21)	-	-
Postoperative pain degree at 1 day
< 7 scores	10 (47.62)	21 (53.85)	0.212	0.645
≥ 7 scores	11 (52.38)	18 (46.15)	-	-

Table 3 Variable assignments.

Independent variable	Type of variable	Evaluate
Age	Classified variable	1: > 60, 0: ≤ 60
Child-Pugh classification of liver function	Classified variable	1: B grade, 0: A grade
Postoperative body temperature	Classified variable	1: ≥ 38 °C, 0: < 38 °C

Table 4 Multiple logistic regression model analysis of the risk factors of electrocardiographic abnormalities in patients with hepatocellular carcinoma intervention.

Factor	Partial regression coefficient	Standard error	Wald	OR	95%CI	P value
Age > 60	1.137	0.312	17.517	2.476	1.634-3.684	< 0.001
Liver function Child-Pugh grade B	1.157	0.344	10.224	2.054	1.179-3.644	< 0.001
Postoperative body temperature ≥ 38 °C	1.304	0.214	22.436	3.585	1.674-6.912	< 0.001

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

The liver, a crucial metabolic organ in the human body, is further compromised by cancer progression and the associated effects of interventional tumor therapy. Damage to liver function causes electrolyte disorders in the body, leading to arrhythmias and abnormal ECG[5] in patients after surgery. Liver cancer intervention is a treatment method for controlling tumor growth using chemotherapeutic drugs. The use of chemotherapeutic drugs also has a negative effect on patients’ hearts. Liver failure, portal hypertension, and other complications caused by liver cancer also aggravate the abnormal ECG performance in patients[6].

In this study, we found that the 24 hours QTV, SDNN (ms), SDANN-index, and SDNN-index levels in the normal group were significantly lower than those in the abnormal group, with statistically significant differences (P < 0.05). When liver function is compromised, detoxification and metabolic capabilities decline, thereby disrupting the physiological functions of the body. Patients exhibit abnormal ECG symptoms such as sinus tachycardia, ST-T changes, prolonged QT intervals, and arrhythmias[7]. In patients with liver cancer, tumor metastasis and local compression can also affect cardiac electrical activity, leading to changes in ECG-related parameters[8]. Additionally, commonly used chemotherapeutic drugs, such as cisplatin, fluorouracil, and doxorubicin, exhibit significant dose-dependent cardiotoxicity. With increasing dosage, the incidence of cardiotoxicity increases significantly, leading to myocardial damage, bundle branch block, and arrhythmias[9].

According to the results of logistic regression analysis, age > 60 years, liver function grade B, and postoperative body temperature 38 °C were risk factors for ECG abnormalities in patients with HCC intervention (P < 0.05). In this study, we observed that older patients with cancer exhibit a diminished capacity to combat cancer, with more pronounced effects of cancer cells on the body and a higher incidence of complications. Age also influences liver function to a certain extent, leading to more significant ECG abnormalities in patients with liver cancer aged > 60 years following interventional treatment[10]. Regarding liver function Child-Pugh grade B: When the liver function is impaired, human metabolism and detoxification processes are affected. The liver is involved in the metabolism of cholesterol and phospholipids. Impaired liver function may lead to an imbalance in the levels of these substances, subsequently affecting cell membrane stability. Cell membrane stability is crucial for maintaining normal heart function, and once affected, it may lead to ECG abnormalities[11]. In addition, the liver is involved in the metabolism of many bioactive substances, such as hormones and neurotransmitters. Impairment of liver function may lead to metabolic disorders of these substances, which, in turn, may affect heart function and ECG performance. A postoperative body temperature of 38 °C indicates significant inflammation or infection in the body[12]. When the body is stimulated by infection or inflammation, the immune system responds quickly by releasing a series of inflammatory mediators, such as cytokines and chemokines, to promote the migration and activation of immune cells. This can cause vascular dilation and increased permeability, allowing immune cells to reach the site of infection and eliminate pathogens[13]. However, massive release of inflammatory mediators during inflammation and infection, and the activation of immune cells may also damage the heart. On the one hand, inflammatory mediators can directly act on heart tissue, damage cardiomyocytes and heart vascular endothelial cells, resulting in impaired heart function; on the other hand, they can also affect the electrophysiological characteristics of the heart, increasing the risk of arrhythmia[14]. In this study, the dataset was constrained, necessitating further analyses of patient medication profiles and adverse reactions to uncover additional factors that may influence ECG abnormalities after interventional surgery for liver cancer. This enables the implementation of targeted preventive measures and ensures the efficacy of interventional procedures.

CONCLUSION

Postoperative body temperature, age, and liver function grade all affected the electrocardiographic parameters in the perioperative period of liver cancer intervention. Postoperative body temperature of 38 °C, age > 60 years, and liver function Child-Pugh grade B are the risk factors for abnormal ECG in patients with liver cancer intervention. Patients with HCC undergoing interventional therapy, particularly those with the aforementioned influencing factors, should be closely monitored for electrocardiographic changes, with enhanced cardiac surveillance and, when necessary, the use of cardioprotective medications to reduce the incidence of myocardial complications.