A new study on the outcome of cardiac surgery in patients with liver cirrhosis found that the surgery can safely be performed in patients with milder disease, while those with more severe cirrhosis are less likely to survive.
The results of this study appear in the July 2007 issue of Liver Transplantation, the official journal of the American Association for the Study of Liver Diseases (AASLD) and the International Liver Transplantation Society (ILTS). The journal is published on behalf of the societies by John Wiley & Sons, Inc. and is available online via Wiley InterScience at http://www.interscience.wiley.com/journal/livertransplantion.
In abdominal surgery, it is well known that the severity of liver cirrhosis, as measured by the Child-Pugh classification (a scoring system used to gauge the severity of liver disease) correlates directly with surgical outcome. However, few studies have reported how these patients fare when undergoing cardiac surgery.
Led by Farzan Filsoufi, of Mt. Sinai Hospital in New York, NY, researchers conducted a retrospective study of patients who underwent cardiac surgery at Mt. Sinai Medical Center between January 1998 and December 2004, and identified 27 patients who had cirrhosis. Of these, 18 patients had cardiac surgery with cardiopulmonary bypass (heart-lung machine) while the other 9 had surgery without using the heart-lung machine.
The results showed that hospital mortality increased significantly according to the Child-Pugh classification, with a mortality rate of 10 percent for those with class A, 18 percent for those with class B, and 67 percent for those with class C. Postoperative complications were also higher in class B and C than in class A. There was no correlation between mortality and the MELD (Model for End-Stage Liver Disease) score, however. Early studies reported a higher mortality for class B and C patients than seen in this study, but more recent studies have shown an improvement in survival rates. The current study confirms lower mortality for class B patients, which is probably due to improvements in surgical techniques and the management of cardiac surgery patients. In addition, there was no mortality for those who had coronary artery bypass surgery off-pump (without the heart-lung machine).
The authors note that alternative treatment strategies are needed for patients with advanced cirrhosis and cardiovascular diseases that require surgery. One potential approach is a combined liver transplant and cardiac operation, and there have been a few positive reports documenting such cases. "Despite early promising results with this combined approach the number of publications remains very limited and further investigations are required to determine the role of this treatment strategy in the armamentarium of cardiac and transplantation surgeons," the authors state. Although hospital mortality decreased in this study, the rates of postoperative complications in class B and C were 55 percent and 100 percent respectively. Surgical trauma and the deleterious effects of cardiopulmonary bypass may explain the increased rate of complications, according to the authors.