Cardiac Surgery in Patients with Liver Cirrhosis: A High Risk Operation Even in Low Grade Liver Disease

Background:
Liver cirrhosis has been shown to be a major preoperative risk factor in patients undergoing cardiac surgery particularly with advanced grade liver dysfunction. We sought to evaluate our clinical outcome in patients with liver cirrhosis undergoing different types of cardiac surgery.

Methods:
Between 9/2005 and 4/2016, 21 patients (mean age 65±12 years, 5 female) with liver cirrhosis who underwent cardiac surgery were reviewed. The severity of liver cirrhosis was assessed using Child-Pugh class and the Model for End Stage Liver Disease (MELD) score. Operations included: isolated CABG (n=10), isolated valve surgery (n=5),combined valve and CABG (n=2), heart transplantation(n=2), LVAD implantation (n=1), and thoracoabdominal surgery (n=1).

Results:
Patient cirrhosis grading according to Child-Turcotte-Pugh was: class A (n =19), B (n =2), and C (n =0). Mean MELD score was 12.0±6.0. The etiology for liver disease was viral hepatitis, non-alcoholic steatohepatitis (NASH), and others or unknown (n=5, 6, 10, respectively). The overall operative mortality was 43% (n=9). Stratified mortality according to Child-Turcotte-Pugh class was 37% (7 out of 19 patients) and 100% for class A and B, respectively. MELD score was similar between operative survivors and non-survivors (12.5±5.9 and 11.3±6.6, respectively, p=0.7). The mortality rate for patients who underwent CABG was 50% (N=5) and for valve and other operations was 36% (n=4), ns. The major reasons for operative mortality were sepsis, mediastinitis or multi organ failure. The 1yr, 3y and 5y survival rate was 59%, 46%, and 37.5%, respectively.

Conclusions:
The current data demonstrates the operative mortality of patients with liver cirrhosis undergoing open-heart surgery is high, even with low grade disease according to Child-Turcotte-Pugh classification. MELD score has not been shown as a risk stratified predictor for mortality. Therefore, extreme caution should be applied while referring patients with liver cirrhosis of any grade to open heart surgery.