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Vohra V, Bhangui P, Bhangui P, Sharma N, Gupta N, Bansal M, Soin AS. Combined Living Donor Liver Transplantation With Coronary Artery Bypass Grafting: Possible but not Without a Struggle. J Clin Exp Hepatol 2025; 15:102515. [PMID: 40135105 PMCID: PMC11930670 DOI: 10.1016/j.jceh.2025.102515] [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] [Received: 11/24/2024] [Accepted: 02/11/2025] [Indexed: 03/27/2025] Open
Abstract
Background A combined liver transplant (LT) and coronary artery bypass grafting (CABG) may sometimes be needed for patients with decompensated cirrhosis who also have significant coronary artery disease (CAD). However, such a procedure is associated with significant morbidity and mortality. Methods From May 2012 to August 2020, eight patients with significant coronary artery disease (CAD) underwent combined off pump CABG (OPCAB) and living donor liver transplantation (LDLT) at our center. We analyzed patient demographics, preoperative clinical findings, operative details, and postoperative outcomes. Results Mean recipient age and body mass index were 59 ± 6 years and 26 ± 3kg/m2, respectively. The model for end-stage liver disease (MELD) score was 20. Four patients each had hypertension and diabetes. Mean total duration of the surgery was 982 ± 117 min, with 598 ± 89 min for living donor liver transplantation (LDLT). The mean volume of packed red blood cell transfusion was 2500ml. The duration of the ventilatory support (median 49 h post-surgery), and the median intensive care unit and hospital stay (8 and 18 days, respectively). Two patients died during the postoperative period due to sepsis with multiorgan failure No recipient had evidence of acute coronary syndrome, stress cardiomyopathy; none required interventional hemodynamic support. Four patients developed atrial arrhythmia's in the post-operative period, all were managed successfully with medical management. Conclusion Combined CABG and LDLT is feasible but poses significant challenges. Careful preprocedure planning, and meticulous intra- and post-operative management involving a multidisciplinary team of LT Surgeons and anesthetists, hepatologists, cardiologists, and cardiac surgeons is required to ensure optimal outcomes in these patients.
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Affiliation(s)
- Vijay Vohra
- Department of Liver Transplant and GI Anaesthesia, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
| | - Pooja Bhangui
- Department of Liver Transplant and GI Anaesthesia, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
| | - Nishant Sharma
- Department of Liver Transplant and GI Anaesthesia, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
| | - Nikunj Gupta
- Department of Liver Transplant and GI Anaesthesia, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
| | - Manish Bansal
- Clinical & Preventive Cardiology, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
| | - Arvinder Singh Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta – The Medicity, Sector 38, Gurgaon, 122001, India
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Saxena A, Tatum R, Chen H, Ahmad D, Rahimov D, Curran J, Kagarise T, Plestis KA, Rajagopal K, Entwistle JW, Tchantchaleishvili V. Outcomes of Cardiac Surgery in Patients With Liver Cirrhosis: A Systematic Review and Meta-Analysis. Cardiol Rev 2025:00045415-990000000-00484. [PMID: 40304510 DOI: 10.1097/crd.0000000000000917] [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: 05/02/2025]
Abstract
Cirrhosis is a progressive form of liver disease associated with significant patient morbidity and mortality. Model for End-Stage Liver Disease (MELD) and Child-Pugh scores are disease severity classification systems that carry predictive value for patients undergoing various procedures. Missing is a granular analysis exploring the association between liver disease severity and clinical outcomes among patients who require cardiac surgery. Our study extracted demographic, periprocedural, and postoperative clinical data for patients with liver cirrhosis undergoing cardiac surgery between 2000 and 2023. Continuous variables were pooled by meta-analysis utilizing a random effects model, and categorical variables were studied using meta-analysis of proportions with logit transformations. The most frequently observed Child-Pugh classification was class A in 60% of patients (95% confidence interval [CI]: 53-67), followed by class B in 33% (95% CI: 27-39) and class C in 4% (95% CI: 2-6). Notably, 30% of patients developed renal failure in the postoperative period (95% CI: 21-39), and overall in-patient mortality occurred in 11% of patients (95% CI: 9-14). There was a significant association between Child-Pugh classification and overall patient survival for 3 years in the postoperative period. No significant relationship was observed between preoperative MELD score and postoperative clinical outcomes. Preoperative Child-Pugh classification is associated with postoperative clinical outcomes among patients undergoing cardiac surgery. More granular data are required to understand the association between MELD scores and postoperative outcomes within the cardiac surgery population.
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Affiliation(s)
- Abhiraj Saxena
- From the Department of Medicine, Rutgers Health Robert Wood Johnson, New Brunswick, NJ
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Rob Tatum
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
- Department of Surgery, University of Vermont, Burlington, VT
| | - Hui Chen
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Danial Ahmad
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
- Division of Cardiac Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Daler Rahimov
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - John Curran
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Tressa Kagarise
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
- Shippensburg University, Shippensburg, PA
| | | | - Keshava Rajagopal
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - John W Entwistle
- Department of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
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Wang XD, Zhao ZZ, Yang XY, Bao R, Wang YY, Lan Y, Quan ZY, Wang JF, Bian JJ. Association Between Red Cell Distribution Width and Liver Injury after Cardiac and Aortic Aneurysm Surgery with Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024; 38:3065-3075. [PMID: 39343626 DOI: 10.1053/j.jvca.2024.09.004] [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: 03/29/2024] [Revised: 08/24/2024] [Accepted: 09/04/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVES This study aimed to investigate the association between preoperative red blood cell distribution width (RDW) levels and liver injury (LI) after cardiac surgery, to highlight RDW's usefulness in the early identification and intervention for patients at high risk of LI. DESIGN A retrospective observational study. SETTING A university-affiliated teaching hospital and tertiary referral center. PARTICIPANTS Adult patients who underwent cardiac and aortic aneurysm surgery at Changhai Hospital in 2021. INTERVENTIONS Postoperative LI was defined by increased liver enzyme levels and/or hyperbilirubinemia, noted from the time of surgery to discharge. Logistic regression analyses were conducted to examine the RDW-LI relationship, with stratified analyses based on age, gender, and anemia. Survival within 30 days was assessed using the Kaplan-Meier method, with survival curve differences analyzed via the log-rank test. The study included 3 sets of sensitivity analyses. MEASUREMENTS AND MAIN RESULTS Postoperative LI was observed in 75 patients (10%). Multivariate regression analysis showed a significant association between high RDW levels and postoperative LI (adjusted odds ratio, 3.25; p = 0.033; 95% confidence intefal, 1.10-9.63), even after adjusting for all covariates. This association remained consistent across 3 sets of sensitivity analyses. Subgroup analysis showed men had a higher correlation with LI (p for interaction = 0.041). Kaplan-Meier analysis indicated a significantly lower survival rate in the LI group (76%) compared with the non-LI group (99.6%; p < 0.001). CONCLUSIONS Preoperative RDW levels are significantly associated with postoperative LI. RDW could serve as a significant useful marker for early detection and intervention in patients at high risk of LI, thereby potentially improving patient outcomes.
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Affiliation(s)
- Xian-Dong Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhen-Zhen Zhao
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xin-Yue Yang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Rui Bao
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yun-Yun Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yang Lan
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhi-Yong Quan
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jia-Feng Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Jin-Jun Bian
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China.
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Shimamura J, Okumura K, Misawa R, Bodin R, Nishida S, Tavolacci S, Malekan R, Lansman S, Spielvogel D, Ohira S. Strategy and Outcomes of Cardiac Surgery in Patients With Cirrhosis: Comprehensive Approach With Liver Transplant Program. Clin Transplant 2024; 38:e15451. [PMID: 39222289 DOI: 10.1111/ctr.15451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 08/06/2024] [Accepted: 08/24/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Cardiac surgery is considered a contraindication in patients with advanced liver cirrhosis (LC) due to increased mortality and morbidity. There are limited data on the treatment strategy and management of this population. We aimed to present our strategy and evaluate the clinical outcome of cardiac surgery in patients with LC. METHODS Our strategy was (i) to list patients for liver transplant (LT) at the time of cardiac surgery; (ii) to maintain high cardiopulmonary bypass (CPB) flow (index up to 3.0 L/min/m2) based on hyper-dynamic states due to LC; and (iii) to proceed to LT if patients' liver function deteriorated with an increasing model for end-stage liver disease Na (MELD-Na) score after cardiac surgery. Thirteen patients (12 male and 1 female [mean age, 63.0]) with LC who underwent cardiac surgery between 2017 and 2024 were retrospectively analyzed. RESULTS Six patients were listed for LT. Indications for cardiac surgery included coronary artery disease (N = 7), endocarditis (N = 2), and tricuspid regurgitation (N = 1), tricuspid stenosis (N = 1), mitral regurgitation (N = 1), and hypertrophic obstructive cardiomyopathy (N = 1). The Child-Pugh score was A in five, B in six, and C in one patient. The procedure included coronary artery bypass grafting (N = 6), single valve surgery (mitral valve [N = 2] and tricuspid valve [N = 1]), concomitant aortic and tricuspid valve surgery (N = 2), and septal myectomy (N = 1). Two patients had a history of previous sternotomy. The perfusion index during CPB was 3.1 ± 0.5 L/min/m2. Postoperative complications include pleural effusion (N = 6), bleeding events (N = 3), acute kidney injury (N = 1), respiratory failure requiring tracheostomy (N = 2), tamponade (N = 1), and sternal infection (N = 1). There was no in-hospital death. There was one remote death due to COVID-19 complication. Preoperative and postoperative highest MELD-Na score among listed patients was 15.8 ± 5.1 and 19.3 ± 5.3, respectively. Five patients underwent LT (1, 5, 8, 16, and 24 months following cardiac surgery) and one patient remains on the list. Survival rates at 1 and 3 years are 100% and 75.0%, respectively. CONCLUSION Cardiac surgery maintaining high CPB flow with LT backup is a feasible strategy in an otherwise inoperable patient population with an acceptable early and midterm survival when performed in a center with an experienced cardiac surgery and LT program.
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Affiliation(s)
- Junichi Shimamura
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Kenji Okumura
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Roxana Bodin
- Division of Transplant Hepatology, Westchester Medical Center, Valhalla, New York, USA
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Sooyun Tavolacci
- Division of Radiation and Research Institute, Westchester Medical Center, Valhalla, New York, USA
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Steven Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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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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Villani R, Loizzi D, Sacco AF, Mirabella L, Santoliquido M, Mongiello D, Sollitto F, Serviddio G. Prevalence and clinical relevance of liver dysfunction after thoracic surgery: a retrospective study. Sci Rep 2023; 13:23045. [PMID: 38155193 PMCID: PMC10754851 DOI: 10.1038/s41598-023-49427-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 12/07/2023] [Indexed: 12/30/2023] Open
Abstract
Postoperative elevation of serum aminotransferase or alkaline phosphatase levels after liver and heart surgeries has been widely reported. The prevalence and clinical significance of hypertransaminasemia/liver dysfunction after thoracic surgery remains largely unknown. Significant differences in surgical procedures between thoracic and extra-thoracic surgeries may suggest different risks of liver dysfunction. We retrospectively analyzed data from 224 consecutive patients who underwent thoracic surgery. Liver function tests were recorded the day before surgery, 12 h, 1 day, 5, and 10 days after the surgical procedure. Patients were studied to identify the frequency of hypertransaminasemia and/or hyperbilirubinemia and/or increase of INR levels. 37,5% of patients showed an increase in serum alanine aminotransferase (ALT) level after thoracic surgery, whereas an increase in gamma glutamyl transferase (GGT) serum levels of any grade was observed in 53,6% of patients. Approximately 83% of patients who experienced an increase in the serum GGT or ALT levels showed a grade 1 or 2 change. Operative time was associated with hypertransaminasemia in the univariate and multivariate analyses, whereas the use of metformin was associated with a lower risk of ALT increase.
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Affiliation(s)
- Rosanna Villani
- C.U.R.E. (University Center for Liver Disease Research and Treatment), Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122, Foggia, Italy.
| | - Domenico Loizzi
- Institute of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Antonia Federica Sacco
- C.U.R.E. (University Center for Liver Disease Research and Treatment), Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122, Foggia, Italy
| | - Lucia Mirabella
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Mariateresa Santoliquido
- C.U.R.E. (University Center for Liver Disease Research and Treatment), Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122, Foggia, Italy
| | - Diletta Mongiello
- Institute of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Francesco Sollitto
- Institute of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Gaetano Serviddio
- C.U.R.E. (University Center for Liver Disease Research and Treatment), Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122, Foggia, Italy
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7
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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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8
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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [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] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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9
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Lifgren SA, Fiala RS, Fabbro M. Blood Transfusions in Elective Cardiac Surgery: The Debate Continues. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00344-0. [PMID: 37344249 DOI: 10.1053/j.jvca.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Sofia A Lifgren
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial Hospital, Miami, FL.
| | - Robert Scott Fiala
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial Hospital, Miami, FL
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10
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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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11
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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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/26/2022] [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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12
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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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13
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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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14
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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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15
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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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Lak HM, Chawla S, Gajulapalli RD, Verma BR, Vural AF, Gad M, Nair R, Shekhar S, Quintini C, Menon KN, Yun J, Burns D, Reed GW, Puri R, Harb S, Krishnaswamy A, Fares M, Kapadia SR. Outcomes After Transfemoral Transcatheter Aortic Valve Implantation With a SAPIEN 3 Valve in Patients With Cirrhosis of the Liver (a Tertiary Care Center Experience). Am J Cardiol 2021; 160:75-82. [PMID: 34583810 DOI: 10.1016/j.amjcard.2021.08.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/10/2021] [Accepted: 08/16/2021] [Indexed: 01/06/2023]
Abstract
Little is known about the utility of transcatheter aortic valve implantation (TAVI) in patients with cirrhosis of the liver, and their outcomes have not been studied extensively in literature. We performed a retrospective analysis of patients with severe symptomatic aortic stenosis (AS) who underwent transfemoral TAVI with a SAPIEN 3 valve at our institution between April 2015 and December 2018. We identified 32 consecutive patients with evidence of cirrhosis of the liver on imaging (including ultrasound and/or computed tomography) and patients with severe symptomatic AS who underwent transfemoral TAVI with a SAPIEN 3 valve. Among 1,028 patients, 32 had cirrhosis of the liver and 996 constituted the control group without cirrhosis. Mean age in the cirrhosis group was 74.5 years compared with 81.2 years in the control group. Baseline variables were comparable between the groups. Compared with the noncirrhotic group, patients with cirrhosis had a similar 1-year mortality (12% vs 12%, p = 1), a lower 30-day new pacemaker after TAVI rate (6% vs 9%, p = 0.85), a higher 30-day and 1-year readmission rate for heart failure (11% vs 1% and 12% vs 5%, p = 0.12, respectively), and a similar 1-year major adverse cardiac and cerebrovascular event rate (15% vs 14%, p = 0.98). In conclusion, patients with severe AS with concomitant liver cirrhosis who underwent TAVI demonstrated comparable outcomes to their noncirrhotic counterparts.
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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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18
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Sawalha K, Gupta K, Kadado AJ, Abozenah M, Battisha A, Salerno C, Khan A, Islam AM. In-hospital outcomes of transcatheter versus surgical mitral valve repair in patients with chronic liver disease. Int J Clin Pract 2021; 75:e14660. [PMID: 34322958 DOI: 10.1111/ijcp.14660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/05/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mitral valve transcatheter edge-to-edge repair (TEER) using MitraClip is a treatment option for patients with moderate to severe mitral regurgitation who are not surgical candidate. Liver cirrhosis is associated with higher operative morbidity and mortality; however, it is not part of preoperative risk assessments calculators. We sought to evaluate the in-hospital outcomes in TEER and surgical mitral valve repair (SMVR) in liver cirrhosis. METHODS National Inpatient Database from 2013 to 2017 was used to obtain all patients with cirrhosis who underwent TEER or SMVR using ICD-9-CM and ICD-10-CM codes. The primary outcome is to compare inpatient mortality between TEER and SMVR. Secondary outcomes were assessed including length of stay (LOS) and rate of complications including cardiogenic shock, blood transfusion and prolonged ventilation. RESULTS A total of 875 patients with cirrhosis who underwent TEER (n = 123) or SMVR (n = 752) were identified in our analysis. Patients with TEER had significantly higher comorbidities such as congestive heart failure, coronary artery disease and chronic obstructive pulmonary disease. In-hospital mortality was lower in TEER group (8.2% vs 16%, P = .04). TEER was associated with lower rates of blood transfusion (30.3% vs 61.2%, P = .02) and reduced rates of prolonged mechanical ventilation (1.2% vs 17.2%, P = .042). In multivariate regression analysis, both blood transfusion and prolonged mechanical ventilation were significant predictors of mortality in liver cirrhosis. CONCLUSIONS TEER was associated with lower rate of in-hospital mortality, LOS, blood transfusion and prolonged mechanical ventilation in cirrhosis patients. TEER can be considered as a viable option for cirrhosis patient with severe mitral regurgitation.
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Affiliation(s)
- Khalid Sawalha
- Department of Internal Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
- Department of Public Health Practice, School of Public Health and Health Sciences, University of New England, Biddeford, Maine, USA
| | - Kamesh Gupta
- Department of Internal Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Anis John Kadado
- Department of Cardiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Mohammed Abozenah
- Department of Internal Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Ayman Battisha
- Department of Internal Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Colby Salerno
- Department of Cardiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Ahmad Khan
- Department of Internal Medicine, West Virginia University, Charleston, West Virginia, USA
| | - Ashequl M Islam
- Department of Cardiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts, USA
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Almalki B, Shroff H, Maddur H, Caicedo J, Kane C. Avatrombopag Use in Patient With Thromboembolic Risks Listed for Combined Coronary Artery Bypass Grafting and Liver Transplant: A Case Report. Transplant Proc 2021; 53:2567-2569. [PMID: 34474911 DOI: 10.1016/j.transproceed.2021.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/07/2021] [Indexed: 02/08/2023]
Abstract
Thrombocytopenia commonly occurs in patients with advanced liver disease and can be a contraindication in patients needing combined coronary artery bypass grafting (CABG) and liver transplant (LT). Thrombopoietin receptor agonists, including avatrombopag, are part of a novel drug class and stimulate platelet production. Avatrombopag is indicated in the perioperative setting to avoid platelet transfusions, which carry several disadvantages. Avatrombopag was shown to be safe and effective in patients with chronic liver disease. This study describes the successful use of avatrombopag in a patient with thromboembolic risks in preparation for a combined CABG and LT. Larger clinical trials are necessary to validate our results.
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Affiliation(s)
- Bassem Almalki
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois; Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Hersh Shroff
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Haripriya Maddur
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Juan Caicedo
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Clare Kane
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
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20
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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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21
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Hyzny EJ, Chan EG, Morrell M, Harano T, Sanchez PG. A review of liver dysfunction in the lung transplant patient. Clin Transplant 2021; 35:e14344. [PMID: 33960530 DOI: 10.1111/ctr.14344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Morrell
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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22
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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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23
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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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Reiter FP, Hadjamu NJ, Nagdyman N, Zachoval R, Mayerle J, De Toni EN, Kaemmerer H, Denk G. Congenital heart disease-associated liver disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:577-590. [PMID: 33968635 DOI: 10.21037/cdt-20-595] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Congenital heart diseases (CHD) can be associated with liver dysfunction. The cause for liver impairment can result out of a wide spectrum of different causes, including liver congestion, hypoxemia or low cardiac output. Fortunately, most CHD show a good long-term outcome from a cardiac perspective, but great attention should be paid on non-cardiac health problems that develop frequently in patients suffering from CHD. The treatment of liver dysfunction in CHD requires a close multidisciplinary management in a vulnerable patient collective. Unfortunately, structured recommendations on the management of liver dysfunction in patients with CHD are scarce. The objective of this review is to provide insights on the pathophysiology and etiologies of liver dysfunction as one of the most relevant non-cardiac problems related to CHD. Furthermore, we advise here on the management of liver disease in CHD with special attention on assessment of liver dysfunction, management of portal hypertension as well as on surveillance and management of hepatocellular carcinoma (HCC). A multidisciplinary perspective may help to optimize morbidity and mortality in the long-term course in these patients. However, as evidence is low in many aspects, we encourage the scientific community to perform prospective studies to gain more insights in the treatment of liver dysfunction in patients with CHD.
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Affiliation(s)
- Florian P Reiter
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Nino J Hadjamu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Nicole Nagdyman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Reinhart Zachoval
- Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Harald Kaemmerer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
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Clinical outcome of cardiac surgery in patients with remitted or active hepatocellular carcinoma. Surg Today 2021; 51:1456-1463. [PMID: 33555435 DOI: 10.1007/s00595-021-02239-z] [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: 08/26/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Hepatocellular carcinoma (HCC) is one of the most common primary cancers worldwide. HCC has unique characteristics such as co-existing chronic liver damage and a high recurrence rate. A negative impact on the surgical outcome due to these backgrounds could be expected. We aimed to evaluate the clinical outcomes of cardiac surgery in these patients. METHODS Between January 2000 and December 2019, 16 patients with remitted cancer and 5 patients with active HCC who underwent open heart surgery were studied. The clinical data were retrospectively evaluated from hospital records. Follow-up information was collected via telephone interviews. RESULTS The major cause of HCC was viral hepatitis. Eighteen patients (86%) were classified as having Child-Pugh class A cirrhosis. The mean model of end-stage liver disease (MELD) score was 7.2 ± 5.2. There was no 30-day mortality. During follow-up, 11 patients died due to HCC. The 1-, 3-, and 5-year survival rates were 80.0, 42.5, and 22.3%, respectively. A univariate analysis identified a higher preoperative MELD score and lower serum cholinesterase levels as prognostic factors for long-term survival. CONCLUSION We could safely perform cardiac surgery in selected patients with remitted and active HCC. The postoperative life expectancy of these patients was limited but acceptable.
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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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Garatti A, Daprati A, Cottini M, Russo CF, Dalla Tomba M, Troise G, Salsano A, Santini F, Scrofani R, Nicolò F, Mikus E, Albertini A, Di Marco L, Pacini D, Picichè M, Salvador L, Actis Dato GM, Centofanti P, Paparella D, Kounakis G, Parolari A, Menicanti L. Cardiac Surgery in Patients With Liver Cirrhosis (CASTER) Study: Early and Long-Term Outcomes. Ann Thorac Surg 2020; 111:1242-1251. [PMID: 32919974 DOI: 10.1016/j.athoracsur.2020.06.110] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/22/2020] [Accepted: 06/26/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking. METHODS All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes. RESULTS The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score <12), or advanced CTP class B (MELD score >12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P = .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P = .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P = .238). CONCLUSIONS CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.
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Affiliation(s)
- Andrea Garatti
- Cardiac Surgery Division, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
| | - Andrea Daprati
- Cardiac Surgery Division, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Marzia Cottini
- Cardiac Surgery Division, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudio F Russo
- Cardiac Surgery Division, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Giovanni Troise
- Cardiac Surgery Division, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Antonio Salsano
- Cardiac Surgery Division, Department of Integrated Surgical and Diagnostic Sciences, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Francesco Santini
- Cardiac Surgery Division, Department of Integrated Surgical and Diagnostic Sciences, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Roberto Scrofani
- Cardiac Surgery Division, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Francesca Nicolò
- Cardiac Surgery Division, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Elisa Mikus
- Cardiac Surgery Division, Maria Cecilia Hospital GVM for Care and Research, Cotignola, Italy
| | - Alberto Albertini
- Cardiac Surgery Division, Maria Cecilia Hospital GVM for Care and Research, Cotignola, Italy
| | - Luca Di Marco
- Cardiac Surgery Division, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Division, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Marco Picichè
- Cardiac Surgery Division, San Bortolo Hospital, Vicenza, Italy
| | - Loris Salvador
- Cardiac Surgery Division, San Bortolo Hospital, Vicenza, Italy
| | | | | | - Domenico Paparella
- Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari Italy; Cardiac Surgery Division, Santa Maria Hospital, GVM Care and Research, Bari, Italy
| | - Giorgios Kounakis
- Cardiac Surgery Division, Santa Maria Hospital, GVM Care and Research, Bari, Italy
| | - Alessandro Parolari
- Universitary Cardiac Surgery, IRCCS Policlinico San Donato and University of Milan, San Donato Milanese, Italy
| | - Lorenzo Menicanti
- Cardiac Surgery Division, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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Sawalha K, Kadado AJ, Gupta K, Al-Akchar M, Battisha A, Abozenah M, Salerno C, Gupta M, Khan A, Islam AM. Outcomes of MitraClip Placement in Patients With Liver Cirrhosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 29:50-53. [PMID: 32839129 DOI: 10.1016/j.carrev.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Liver cirrhosis is associated with increased morbidity and mortality. Many preoperative risk assessment tools do not take into account the presence or degree of liver cirrhosis prior to surgery. Over recent years, percutaneous mitral valve repair using MitraClip has emerged as an option for patients at high risk of surgical intervention. However, the safety, efficacy and outcomes of this procedure in patients with liver cirrhosis have not yet been evaluated. METHODS This is a retrospective cohort study using the 2013-2017 National Inpatient Sample database of adults who were hospitalized for MitraClip repair of mitral valve. All patients were divided into patients with cirrhosis and those without cirrhosis. The primary outcome was all-cause mortality in patient with cirrhosis who underwent MitraClip. The secondary outcomes were to assess length of stay (LOS) and total hospital cost per year in cirrhotic patients compared to non-cirrhotic patients. RESULTS In-hospital mortality was higher in cirrhosis group compared to non-cirrhosis however not statistically significant (8.1% vs 3.2%, OR: 2.59 [95% CI: 0.47-14.28, p-value 0.27). Additionally, neither of the secondary outcomes, LOS and total cost, were found to be statistically significant. However, the incidence of cardiogenic shock was significantly higher in the cirrhosis group 13.3% versus 3.9% (p-value 0.032). CONCLUSION Patients with liver cirrhosis who underwent MitraClip repair of MV were at higher risk of developing cardiogenic shock, without any significant increase in in-hospital mortality, LOS or total cost. However, this study showed a trend toward higher rates of mortality, requirement of blood transfusion, mechanical ventilation, length of stay, and cost of care in cirrhosis patients.
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Affiliation(s)
- Khalid Sawalha
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America; Department of Public Health Practice, School of Public Health and Health Sciences, University of New England, Biddeford, ME, United States of America.
| | - Anis John Kadado
- Department of Cardiology, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Kamesh Gupta
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Mohammad Al-Akchar
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Ayman Battisha
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Mohammed Abozenah
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Colby Salerno
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Manish Gupta
- Department of Internal Medicine, Danbury Hospital, CT, United States of America
| | - Ahmad Khan
- Department of Internal Medicine, West Virginia University, Charleston, WV, United States of America
| | - Ashequl M Islam
- Department of Cardiology, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Ultrasonographic assessment of right heart intracardiac mass in patients with hepatitis B virus infection. Eur J Gastroenterol Hepatol 2020; 32:838-843. [PMID: 31725029 DOI: 10.1097/meg.0000000000001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The characteristics of right heart intracardiac mass in hepatitis B virus infection patients are not well known. Our aim is to describe their ultrasonographic features and nature of such masses. METHODS We retrospectively reviewed imaging reports of hepatitis B virus infection patients from January 2014 to December 2018. Patients with a confirmed finding of right heart intracardiac mass were included, whose pathology reports and contrast-enhanced images were analyzed. Various masses were compared to a general control group from a published study. RESULTS Thirty-eight cases were finally included. Different types of masses presented with a variety of echocardiographic manifestations. Thirty-six cases had masses located in the right atrium, including five thrombus and 31 metastatic carcinoma. The later included one metastatic non-Hodgkin lymphoma and 30 metastatic hepatic carcinoma cases (27 of which had inferior vena cava tumor thrombus). Two cases presented with masses in the right ventricle that included one multiple myxoma and one tricuspid valve leaflet vegetation. Compared with the general population, no primary malignant tumor was found in our study (65% vs. 100%, P = 0.001), and hepatic metastasis was the most common type of malignant tumors (P < 0.001). CONCLUSION The nature and ultrasonographic features of right heart intracardiac masses in hepatitis B virus infection patients are diverse, and the incidence of malignant tumors was similar to that seen in the general population. Hepatic metastasis, possibly extending via the inferior vena cava into the right atrium, was the most common type. Our study may improve understanding of the right heart intracardiac mass in hepatitis B virus infection patients.
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Safety and Outcomes of Combined Liver Transplantation and Cardiac Surgery in Cirrhosis. Ann Thorac Surg 2020; 111:62-68. [PMID: 32585202 DOI: 10.1016/j.athoracsur.2020.04.135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 04/09/2020] [Accepted: 04/30/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Decompensation of liver function after cardiac surgery in patients with cirrhosis has resulted in high morbidity and mortality. A treatment strategy, for which there is a scarcity of data in the literature, encompasses combined liver transplantation and cardiac surgery. METHODS We performed a retrospective analysis of prospectively collected data on 15 patients who underwent combined liver transplantation and cardiac surgery between 2005 to 2017 at our institution. RESULTS Between 2005 and 2017, 15 patients with cirrhosis and coronary artery disease or valve disease were identified who underwent combined liver transplantation and cardiac surgery. The cardiac disease was considered severe enough to preclude liver transplantation alone. Likewise, the advanced cirrhosis precluded cardiac surgery alone. Eighty percent of the patients were male and average age was 60 years. Six patients had coronary artery disease, 2 patients had severe aortic stenosis and coronary artery disease, 1 patient had severe mitral regurgitation and coronary artery disease, 2 patients had severe aortic stenosis, 1 patient had mitral valve prolapse, and 3 patients had severe aortic insufficiency. The mean model for end-stage liver disease score was 24. Four subjects were Child-Pugh class B, and 11 were class C. One-year survival was 73.3%. CONCLUSIONS Combined liver transplant and cardiac surgery is feasible in this selected, otherwise inoperable, patient population with an acceptable early and midterm survival when performed in high volume centers with a cohesive multidisciplinary team.
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Jha AK, Lata S. Liver transplantation and cardiac illness: Current evidences and future directions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:225-241. [PMID: 31975575 DOI: 10.1002/jhbp.715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Contraindications to liver transplantation are gradually narrowing. Cardiac illness and chronic liver disease may manifest independently or may be superimposed on each other due to shared pathophysiology. Cardiac surgery involving the cardiopulmonary bypass in patients with Child-Pugh Class C liver disease is associated with a high risk of perioperative morbidity and mortality. Liver transplantation involves hemodynamic perturbations, volume shifts, coagulation abnormalities, electrolyte disturbances, and hypothermia, which may prove fatal in patients with cardiac illness depending upon the severity. Additionally, cardiovascular complications are the major cause of adverse postoperative outcomes after liver transplantation even in the absence of cardiac pathologies. Clinical decision-making has remained an unsettled issue in these clinical scenarios. The absence of randomized clinical studies has further crippled our endeavours for a consensus on the management of patients with end-stage liver disease with cardiac illness. This review seeks to address this complex clinical setting by gathering information from published literature. The management algorithm in this review may facilitate clinical decision making and augur future research.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Ma X, Zhao D, Li J, Wei D, Zhang J, Yuan P, Kong X, Ma J, Ma H, Sun L, Zhang Y, Jiao Q, Wang Z, Zhang H. Transcatheter aortic valve implantation in the patients with chronic liver disease: A mini-review and meta-analysis. Medicine (Baltimore) 2020; 99:e19766. [PMID: 32311980 PMCID: PMC7220505 DOI: 10.1097/md.0000000000019766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Chronic liver disease is traditionally conceived as a risk factor for cardiovascular surgery. Transcatheter aortic valve implantation (TAVI) has recently burgeoned to precede surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis at intermediate to high surgical risk. The evidence regarding TAVI in the patients with chronic liver disease is currently scarce. METHODS This article aims to assess the application of TAVI technique in the patients with chronic liver disease. RESULTS TAVI in the patients with chronic liver disease produced acceptable postoperative results. The post-TAVI outcomes were comparable between the patients with or without chronic liver disease, except for a lower rate of pacemaker implantation in the patients with chronic liver disease (OR, 0.49[0.27-0.87], P = .02). In the patients with chronic liver disease, compared to SAVR, TAVI led to a decrease in the in-hospital mortality (OR, 0.43[0.22-0.86], P = .02) and need for transfusion (OR, 0.39[0.25-0.62], P < .0001). The rest outcomes were similar between the 2 groups. CONCLUSIONS This systematic review and meta-analysis supported that TAVI is a reliable therapeutic option for treating severe aortic stenosis in the patients with chronic liver disease. Future large-scale randomized controlled trials investigating the mid-term and long-term prognosis are needed to further verify these results.
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Affiliation(s)
- Xiaochun Ma
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
| | - Diming Zhao
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
- School of Medicine, Shandong University, No. 44 Wenhua West Road, Jinan, Shandong 250012
| | - Jinzhang Li
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
- School of Medicine, Shandong University, No. 44 Wenhua West Road, Jinan, Shandong 250012
| | - Dong Wei
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
- School of Medicine, Shandong University, No. 44 Wenhua West Road, Jinan, Shandong 250012
| | - Jianlin Zhang
- School of Medicine, Shandong University, No. 44 Wenhua West Road, Jinan, Shandong 250012
| | - Peidong Yuan
- School of Medicine, Shandong University, No. 44 Wenhua West Road, Jinan, Shandong 250012
| | | | | | - Huibo Ma
- Qingdao University Medical College, Qingdao University, 308 Ningxia Road, Qingdao, 266071, China
| | - Liangong Sun
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
| | | | - Qiqi Jiao
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Jinan, Shandong 250021
| | - Zhengjun Wang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
| | - Haizhou Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, and Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Jinan, Shandong 250021
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De Gasperi A, Spagnolin G, Ornaghi M, Petrò L, Biancofiore G. Preoperative cardiac assessment in liver transplant candidates. Best Pract Res Clin Anaesthesiol 2020; 34:51-68. [PMID: 32334787 DOI: 10.1016/j.bpa.2020.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
New and extended indications, older age, higher cardiovascular risk, and the long-standing cirrhosis-associated complications mandate specific skills for an appropriate preoperative assessment of the liver transplant (LT) candidate. The incidence of cardiac diseases (dysrhythmias, cardiomyopathies, coronary artery disease, valvular heart disease) are increasing among LT recipients: however, no consensus exists among clinical practice guidelines for cardiovascular screening and risk stratification. In spite of different "transplant center-centered protocols", basic "pillars" are common (electrocardiography, baseline echocardiography, functional assessment). Owing to intrinsic limitations, yields and relevance of noninvasive stress tests, under constant scrutiny even if used, are discussed, focusing the definition of the "high risk" candidate and exploring noninvasive imaging and new forms of stress imaging. The aim is to find an appropriate and rational stepwise algorithm. The final commitment is to select the right candidate for a finite resource, the graft, able to save (and change) lives.
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Affiliation(s)
- Andrea De Gasperi
- 2°Servizio Anesthesia Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Gregorio Spagnolin
- 2°Servizio Anesthesia Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Ornaghi
- 2°Servizio Anesthesia Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Petrò
- 2°Servizio Anesthesia Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gianni Biancofiore
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
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Reverter E, Cirera I, Albillos A, Debernardi-Venon W, Abraldes JG, Llop E, Flores A, Martínez-Palli G, Blasi A, Martínez J, Turon F, García-Valdecasas JC, Berzigotti A, de Lacy AM, Fuster J, Hernández-Gea V, Bosch J, García-Pagán JC. The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery. J Hepatol 2019; 71:942-950. [PMID: 31330170 DOI: 10.1016/j.jhep.2019.07.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Surgery in cirrhosis is associated with a high morbidity and mortality. Retrospectively reported prognostic factors include emergency procedures, liver function (MELD/Child-Pugh scores) and portal hypertension (assessed by indirect markers). This study assessed the prognostic role of hepatic venous pressure gradient (HVPG) and other variables in elective extrahepatic surgery in patients with cirrhosis. METHODS A total of 140 patients with cirrhosis (Child-Pugh A/B/C: 59/37/4%), who were due to have elective extrahepatic surgery (121 abdominal; 9 cardiovascular/thoracic; 10 orthopedic and others), were prospectively included in 4 centers (2002-2011). Hepatic and systemic hemodynamics (HVPG, indocyanine green clearance, pulmonary artery catheterization) were assessed prior to surgery, and clinical and laboratory data were collected. Patients were followed-up for 1 year and mortality, transplantation, morbidity and post-surgical decompensation were studied. RESULTS Ninety-day and 1-year mortality rates were 8% and 17%, respectively. Variables independently associated with 1-year mortality were ASA class (American Society of Anesthesiologists), high-risk surgery (defined as open abdominal and cardiovascular/thoracic) and HVPG. These variables closely predicted 90-, 180- and 365-day mortality (C-statistic >0.8). HVPG values >16 mmHg were independently associated with mortality and values ≥20 mmHg identified a subgroup at very high risk of death (44%). Twenty-four patients presented persistent or de novo decompensation at 3 months. Low body mass index, Child-Pugh class and high-risk surgery were associated with death or decompensation. No patient with HVPG <10 mmHg or indocyanine green clearance >0.63 developed decompensation. CONCLUSIONS ASA class, HVPG and high-risk surgery were prognostic factors of 1-year mortality in cirrhotic patients undergoing elective extrahepatic surgery. HVPG values >16 mmHg, especially ≥20 mmHg, were associated with a high risk of post-surgical mortality. LAY SUMMARY The hepatic venous pressure gradient is associated with outcomes in patients with cirrhosis undergoing elective extrahepatic surgery. It enables a better stratification of risk in these patients and provides the foundations for potential interventions to improve post-surgical outcomes.
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Affiliation(s)
- Enric Reverter
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Isabel Cirera
- Gastroenterology and Hepatology, Hospital del Mar, Barcelona, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Juan G Abraldes
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Elba Llop
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Alexandra Flores
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
| | - Javier Martínez
- Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Annalisa Berzigotti
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Antoni M de Lacy
- Gastrointestinal Surgery Department, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
| | - Josep Fuster
- Hepatobiliary and Pancreatic Surgery Department, Hospital Clínic. IDIBAPS, University of Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Joan Carles García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
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The impact of cirrhosis in patients undergoing cardiac surgery: a retrospective observational cohort study. Can J Anaesth 2019; 67:22-31. [PMID: 31571117 DOI: 10.1007/s12630-019-01493-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 07/12/2019] [Accepted: 09/24/2019] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Patients with cirrhosis and concomitant coronary/valvular heart disease present a clinical dilemma. The therapeutic outcome of major cardiac surgery is significantly poorer in patients with cirrhosis compared with patients without cirrhosis. To address this, we aimed to identify associations between the severity of cirrhosis and post-cardiac surgical outcomes. METHODS A historical cohort analysis of patients undergoing cardiac surgery at the University of Alberta Hospital from January 2004 to December 2014 was used to identify and propensity score-match 60 patients with cirrhosis to 310 patients without cirrhosis. The relationships between cirrhosis and i) mortality, ii) postoperative complications, and iii) requirement of healthcare resources were evaluated. RESULTS Ten-year mortality was significantly higher in cirrhotic patients compared with propensity score-matched non-cirrhotic patients (40% vs 20%; relative risk [RR], 2.0; 95% confidence interval [CI], 1.3 to 2.9; P = 0.001). Cirrhotic patients had more complications (63% vs 48%; RR, 1.3; 95% CI, 1.05 to 1.7; P = 0.02), longer median [interquartile range (IQR)] intensive care unit stays (5 [3-11] vs 2 [1-4] days; P < 0.001), time on mechanical ventilation (median [IQR] 2 [1-5] vs 1 [0.5-1.2] days; P < 0.001) and more frequently required renal replacement therapy (15% vs 6%; RR, 2.5; 95% CI, 1.2 to 5.2; P = 0.02) postoperatively. After adjusting for other covariates, presence of cirrhosis (adjusted odds ratio, 2.2; 95% CI, 1.1 to 4.1) and intraoperative transfusion (adjusted odds ratio, 3.2; 95% CI, 1.6 to 6.3) were independently associated with increased mortality. CONCLUSION Despite having low median model for end-stage liver disease scores, this small series of cirrhotic patients undergoing cardiac surgery had significantly higher mortality rates and required more organ support postoperatively than propensity score-matched non-cirrhotic patients. Impact de la cirrhose chez les patients subissant une chirurgie cardiaque : une étude de cohorte observationnelle et rétrospective.
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Clinical Outcomes of Transcatheter vs Surgical Aortic Valve Replacement in Patients With Chronic Liver Disease: A Systematic Review and Metaanalysis. Ochsner J 2019; 19:241-247. [PMID: 31528135 DOI: 10.31486/toj.18.0178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Chronic liver disease increases cardiac surgical risk, with 30-day mortality ranging from 9% to 52% in patients with Child-Pugh class A and C, respectively. Data comparing the outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with liver disease are limited. Methods: We searched PubMed, Cochrane Library, Web of Science, and Google Scholar for relevant studies and assessed risk of bias using the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) Cochrane Collaboration tool. Results: Five observational studies with 359 TAVR and 1,872 SAVR patients were included in the analysis. Overall, patients undergoing TAVR had a statistically insignificant lower rate of in-hospital mortality (7.2% vs 18.1%; odds ratio [OR] 0.67; 95% confidence interval [CI] 0.25, 1.82; I2=61%) than patients receiving SAVR. In propensity score-matched cohorts, patients undergoing TAVR had lower rates of in-hospital mortality (7.3% vs 13.2%; OR 0.51; 95% CI 0.27, 0.98; I2=13%), blood transfusion (27.4% vs 51.1%; OR 0.36; 95% CI 0.21, 0.60; I2=31%), and hospital length of stay (10.9 vs 15.7 days; mean difference -6.32; 95% CI -10.28, -2.36; I2=83%) than patients having SAVR. No significant differences between the 2 interventions were detected in the proportion of patients discharged home (65.3% vs 53.9%; OR 1.3; 95% CI 0.56, 3.05; I2=67%), acute kidney injury (10.4% vs 17.1%; OR 0.55; 95% CI 0.29, 1.07; I2= 0%), or mean cost of hospitalization ($250,386 vs $257,464; standardized mean difference -0.07; 95% CI -0.29, 0.14; I2=0%). Conclusion: In patients with chronic liver disease, TAVR may be associated with lower rates of in-hospital mortality, blood transfusion, and hospital length of stay compared with SAVR.
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Mahmud N, Fricker Z, Serper M, Kaplan DE, Rothstein KD, Goldberg DS. In-Hospital mortality varies by procedure type among cirrhosis surgery admissions. Liver Int 2019; 39:1394-1399. [PMID: 31141306 PMCID: PMC6675652 DOI: 10.1111/liv.14156] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/01/2019] [Accepted: 05/22/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with cirrhosis have increased peri-operative mortality risk relative to non-cirrhotic patients, however, the impact of surgical procedure category on this risk is poorly understood. METHODS We performed a retrospective cohort study of cirrhosis surgery admissions using the National Inpatient Sample between 2012 and 2014 to estimate the adjusted odds of in-hospital mortality by surgical procedure category. RESULTS In-hospital mortality differed by surgical procedure category. Relative to major orthopedic surgeries, major abdominal surgeries had the highest odds of in-hospital mortality (odds ratio [OR] 8.27, 95% confidence interval [CI] 5.96-11.49), followed by major cardiovascular surgeries (OR 3.45, 95% CI 2.33-5.09). There was also a significant interaction term, whereby elective/non-elective admission status impacted in-hospital mortality risk differently for each surgical procedure category (P < 0.001). CONCLUSION In-hospital mortality varies substantially by surgical procedure type. Accounting for procedure type in models may improve risk prediction for peri-operative mortality in patients with cirrhosis.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Zachary Fricker
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Kenneth D. Rothstein
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Farag M, Veres G, Szabó G, Ruhparwar A, Karck M, Arif R. Hyperbilirubinaemia after cardiac surgery: the point of no return. ESC Heart Fail 2019; 6:694-700. [PMID: 31095903 PMCID: PMC6676269 DOI: 10.1002/ehf2.12447] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/09/2019] [Indexed: 01/15/2023] Open
Abstract
Aims The occurrence of hyperbilirubinaemia after heart surgery using cardiopulmonary bypass or post‐operative heart failure is fairly common. We investigated the incidence, predictive value, and post‐operative outcome of hyperbilirubinaemia after cardiac surgery in an effort to identify potential risk factors and significance on clinical outcome. Methods and results Between 2006 and 2016, 1272 (10.1%) out of 12 556 patients developed hyperbilirubinaemia, defined as bilirubin concentration >3 mg/dL, during post‐operative course at our institution. All patients who were operated using cardiopulmonary bypass were included. Hepatic dysfunction was diagnosed preoperatively in 200 patients (15.7%), whereas mean model of end‐stage liver disease score was 11.22 ± 4.99. Early mortality was 17.4% with age [hazard ratio (HR) 1.019, 95% confidence interval (CI) 1.008–1.029; P = 0.001], diabetes (HR 1.115, CI 1.020–1.220; P = 0.017), and emergent procedures (HR 1.315, CI 1.012–1.710) as multivariate predictors. Post‐operative predictors were low‐output syndrome (HR 3.193, 95% CI 2.495–4.086; P < 0.001), blood transfusion (HR 1.0, CI 1.0–1.0; P < 0.001), and time to peak bilirubin (HR 1.1, CI 1.0–1.1; P < 0.001). We found an increased correlation with mortality at 3.5 post‐operative day as well as an optimal cut‐off value for bilirubin of 5.35 mg/dL. A maximum bilirubin of 25.5 mg/dL was associated with 99% mortality. Survival analysis showed significantly decreased survival for patients who developed late, rather than early, hyperbilirubinaemia. Conclusions Post‐operative hyperbilirubinaemia is a prevalent threat after cardiopulmonary bypass, associated with high early mortality. The timing and amount of peak bilirubin concentration are linked to the underlying pathology and are predictors of post‐operative outcome. Patients with late development of steep hyperbilirubinaemia warrant meticulous post‐operative care optimizing cardiac and end organ functions before reaching the point of no return.
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Affiliation(s)
- Mina Farag
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabor Veres
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabor Szabó
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
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40
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Higuchi R, Tobaru T, Hagiya K, Saji M, Mahara K, Takamisawa I, Shimizu J, Iguchi N, Takanashi S, Takayama M, Isobe M. Outcomes of Transcatheter Aortic Valve Implantation in Patients with Cirrhosis. Int Heart J 2019; 60:352-358. [DOI: 10.1536/ihj.18-339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | | | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute
| | | | | | - Jun Shimizu
- Department of Anesthesiology, Sakakibara Heart Institute
| | - Nobuo Iguchi
- Department of Cardiology, Sakakibara Heart Institute
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41
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Singh V, Savani GT, Mendirichaga R, Jonnalagadda AK, Cohen MG, Palacios IF. Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis. Am J Cardiol 2018; 122:1853-1861. [PMID: 30293650 DOI: 10.1016/j.amjcard.2018.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 01/20/2023]
Abstract
Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years.
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Affiliation(s)
- Vikas Singh
- Division of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky.
| | - Ghanshyambhai T Savani
- Department of Medicine, Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts
| | - Rodrigo Mendirichaga
- Division of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Anil K Jonnalagadda
- Department of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia
| | - Mauricio G Cohen
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Massachusetts
| | - Igor F Palacios
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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42
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Chacon MM, Schulte TE. Liver Dysfunction in Cardiac Surgery – What Causes It and Is There Anything We Can Do? J Cardiothorac Vasc Anesth 2018; 32:1719-1721. [DOI: 10.1053/j.jvca.2018.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 11/11/2022]
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Yassin AS, Subahi A, Abubakar H, Akintoye E, Alhusain R, Adegbala O, Ahmed A, Elmoughrabi A, Subahi E, Pahuja M, Sahlieh A, Elder M, Kaki A, Schreiber T, Mohamad T. Outcomes and Effects of Hepatic Cirrhosis in Patients Who Underwent Transcatheter Aortic Valve Implantation. Am J Cardiol 2018; 122:455-460. [PMID: 30041889 DOI: 10.1016/j.amjcard.2018.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/09/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without liver cirrhosis are scarce. This study aimed to assess the clinical outcomes and impact of liver cirrhosis on patients who underwent TAVI. Patient with liver cirrhosis who underwent TAVI 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of liver cirrhosis on inpatient mortality. Secondary outcomes were the impact of liver cirrhosis on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The cirrhotic patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.59 to 2.10, p = 0.734) or after procedural complications. Furthermore, cirrhotic patients were less likely to develop vascular complications requiring surgery (OR 0.47, 95% CI 0.23 to 0.98, p = 0.043), to develop after procedural deep vein thrombosis(OR <0.00, 95% CI <0.001 to <0.0001, p <0.0001), and to require pacemaker implantation. However, cirrhotic patients were more likely to undergo nonroutine hospital discharges (OR 1.50, 95% CI 1.15 to 1.96, p = 0.003). In conclusion, TAVI is a safe and reasonable therapeutic option for cirrhotic patients with severe aortic stenosis, requiring aortic valve replacement.
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Affiliation(s)
- Ahmed S Yassin
- Department of Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan.
| | - Ahmed Subahi
- Department of Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan
| | - Hossam Abubakar
- Department of Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan
| | - Emmanuel Akintoye
- Department of Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan
| | - Rashid Alhusain
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Oluwole Adegbala
- Department of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, New Jersey
| | - Abdelrahman Ahmed
- Department of Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan
| | - Adel Elmoughrabi
- Department of Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan
| | - Eihab Subahi
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Mohit Pahuja
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Ali Sahlieh
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Mahir Elder
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Amir Kaki
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Theodore Schreiber
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Tamam Mohamad
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
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Gitman M, Albertz M, Nicolau-Raducu R, Aniskevich S, Pai SL. Cardiac diseases among liver transplant candidates. Clin Transplant 2018; 32:e13296. [PMID: 29804298 DOI: 10.1111/ctr.13296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2018] [Indexed: 11/29/2022]
Abstract
Improvements in early survival after liver transplant (LT) have allowed for the selection of LT candidates with multiple comorbidities. Cardiovascular disease is a major contributor to post-LT complications. We performed a literature search to identify the causes of cardiac disease in the LT population and to describe techniques for diagnosis and perioperative management. As no definite guidelines for preoperative assessment (except for pulmonary heart disease) are currently available, we recommend an algorithm for preoperative cardiac work-up.
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Affiliation(s)
- Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL, USA
| | - Megan Albertz
- Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Stephen Aniskevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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Tirado-Conte G, Rodés-Cabau J, Rodríguez-Olivares R, Barbanti M, Lhermusier T, Amat-Santos I, Toggweiler S, Cheema AN, Muñoz-García AJ, Serra V, Giordana F, Veiga G, Jiménez-Quevedo P, Campelo-Parada F, Loretz L, Todaro D, del Trigo M, Hernández-García JM, García del Blanco B, Bruno F, de la Torre Hernández JM, Stella P, Tamburino C, Macaya C, Nombela-Franco L. Clinical Outcomes and Prognosis Markers of Patients With Liver Disease Undergoing Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2018; 11:e005727. [DOI: 10.1161/circinterventions.117.005727] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/16/2018] [Indexed: 02/06/2023]
Abstract
Background—
Chronic liver disease is a known risk factor for perioperative morbidity and mortality in patients undergoing cardiac surgery. Very little data exist about such patients treated with transcatheter aortic valve replacement (TAVR). Our objective was to evaluate early and late clinical outcomes in a large cohort of patients with liver disease undergoing TAVR and to determine predictive factors of mortality among these patients.
Methods and Results—
This multicenter study collected data from 114 patients with chronic liver disease who underwent TAVR in 12 institutions. Perioperative and long-term outcomes were compared with a cohort of 1118 patients without liver disease after a propensity score–matching analysis (114 matched pairs). In-hospital mortality and vascular and bleeding complications were similar between matched groups. Acute kidney injury was more common in liver disease group (30.8% versus 13.5%;
P
=0.010). Although cardiovascular mortality was similar between groups (9.4% versus 6.5%;
P
=0.433) at 2-year follow-up, noncardiac mortality was higher in the liver group (26.4% versus 14.8%;
P
=0.034). Lower glomerular filtration rate (hazard ratio, 1.10, for each decrease of 5 mL/min in estimated glomerular filtration rate; 95% confidence interval, 1.03–1.17;
P
=0.005) and Child-Pugh class B or C (hazard ratio, 3.11; 95% confidence interval, 1.47–6.56;
P
=0.003) were the predictors of mortality in patients with chronic liver disease, with a mortality rate of 83.2% at 2-year follow-up in patients with both factors (estimated glomerular filtration rate <60 mL/min and Child-Pugh B or C).
Conclusions—
These findings suggested that TAVR is a feasible treatment for severe aortic stenosis in patients with early-stage liver disease or as bridge therapy before a curative treatment of the hepatic condition. Patients with Child-Pugh class B-C, especially in combination with renal impairment, had a very low survival rate, and TAVR should be carefully considered to avoid a futile treatment. These results may contribute to improve the clinical decision-making process and management in patients with liver disease.
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Affiliation(s)
- Gabriela Tirado-Conte
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Josep Rodés-Cabau
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Ramón Rodríguez-Olivares
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Marco Barbanti
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Thibault Lhermusier
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Ignacio Amat-Santos
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Stefan Toggweiler
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Asim N. Cheema
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Antonio J. Muñoz-García
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Vicenc Serra
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Francesca Giordana
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Gabriela Veiga
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Pilar Jiménez-Quevedo
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Francisco Campelo-Parada
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Lucca Loretz
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Denise Todaro
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - María del Trigo
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - José M. Hernández-García
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Bruno García del Blanco
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Francesco Bruno
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - José M. de la Torre Hernández
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Pieter Stella
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Corrado Tamburino
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Carlos Macaya
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
| | - Luis Nombela-Franco
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Universidad Complutense, IdISSC, Madrid, Spain (G.T.-C., P.J.-Q., M.d.T., C.M., L.N.-F.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., F.C.-P., M.d.T.); Department of Cardiology, Utrecht Medisch Centrum, the Netherlands (R.R.-O., P.S.); Department of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., C.T.); Department of Cardiology, Rangueil
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Cheung CY, Chok KSH, Lee OJ, Lo KS, Chan SC, Lo CM. Asia's first combined liver transplant and aortic valve replacement. Hepatobiliary Pancreat Dis Int 2018; 17:86-87. [PMID: 29428111 DOI: 10.1016/j.hbpd.2018.01.011] [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: 03/23/2017] [Accepted: 08/17/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Chung Yeung Cheung
- Department of Surgery, Queen Mary Hospital, 102 Pok Fu Lam Road, Hong Kong, China
| | - Kenneth S H Chok
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Oswald J Lee
- Department of Cardiothoracic Surgery, Queen Mary Hospital, 102 Pok Fu Lam Road, Hong Kong, China
| | - Kevin S Lo
- Department of Anesthesiology, Queen Mary Hospital, 102 Pok Fu Lam Road, Hong Kong, China
| | - See Ching Chan
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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47
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Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e348-e392. [DOI: 10.1161/cir.0000000000000535] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.
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48
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Increased serum Wisteria floribunda agglutinin positive Mac-2 binding protein (Mac-2 binding protein glycosylation isomer) in chronic heart failure: a pilot study. Heart Vessels 2017; 33:385-392. [PMID: 29098408 DOI: 10.1007/s00380-017-1071-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 10/20/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Serum Wisteria floribunda agglutinin positive Mac-2 binding protein (WFA+-M2BP) or Mac-2 Binding Protein Glycosylation Isomer (M2BPGi) is a novel biomarker currently applied for evaluating hepatic fibrosis. The aim of this study was to evaluate the utility of serum WFA+-M2BP level as a biomarker in chronic heart failure (HF) patients with abnormal liver function. METHODS AND RESULTS Fifty chronic HF patients who underwent measurement of serum WFA+-M2BP were evaluated. The median value of serum WFA+-M2BP was 0.88 (interquartile range 0.48-1.29) cut-off index, and positive WFA+-M2BP (≥ 1.00 cut-off index) was observed in 22 (44%). Elevated WFA + -M2BP was associated with longer HF history, older age, female sex, valvular heart disease, decreased estimated glomerular filtration rate (eGFR), albumin, and cholinesterase. Stepwise multiple regression analysis showed that HF history, eGFR, and albumin were independent determinants of serum WFA+-M2BP values. Repeated measurements of serum WFA+-M2BP suggested association between the decrease of WFA+-M2BP and improvement of New York Heart Association (NYHA) functional class. CONCLUSIONS Elevation of serum WFA+-M2BP showed a high prevalence in chronic HF patients with abnormal liver function with relation to HF history, decreased hepatic protein synthesis, and renal dysfunction. Our results suggest that serum WFA+-M2BP may be a novel biomarker of chronic HF.
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49
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Outcomes of Transcatheter Versus Surgical Aortic Valve Implantation for Aortic Stenosis in Patients With Hepatic Cirrhosis. Am J Cardiol 2017; 120:1193-1197. [PMID: 28803656 DOI: 10.1016/j.amjcard.2017.06.067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/05/2017] [Accepted: 06/26/2017] [Indexed: 11/24/2022]
Abstract
Current risk prediction tools for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) do not include variables associated with clinically significant hepatic disease. Accordingly, outcome data of TAVI or SAVR in patients with liver cirrhosis are limited. We sought to assess contemporary trends and outcomes of TAVI and SAVR in patients with liver cirrhosis using a national database. The Nationwide Inpatient Sample was used to identify patients with liver cirrhosis who underwent TAVI or SAVR between 2003 and 2014. Outcomes of propensity-matched groups of patients undergoing TAVI or SAVR were assessed. The reported number of TAVI and SAVR procedures in patients with liver cirrhosis increased from 376 cases in 2003 to 1,095 cases in 2014. A total of 1,766 patients with liver cirrhosis who underwent TAVI (n = 174) or SAVR (n = 1,592) were included in the analysis. In-hospital mortality was higher in patients who underwent SAVR versus TAVI (20.2% vs 8%, p <0.001). Major adverse events were also more frequent after SAVR. Propensity matching attained 2 groups of 268 patients who underwent TAVI (n = 134) or SAVR (n = 134). Following propensity matching, in-hospital mortality remained higher in the SAVR group (18.7% vs 8.2%, p = 0.018), but major adverse events were not different between the 2 groups. Hospital length of stay was longer, and nonhome disposition rates were higher in the SAVR group. In conclusion, the number of reported TAVI and SAVR in patients with liver cirrhosis and aortic stenosis increased 3-folds between 2003 and 2014. In these patients, TAVI was associated with lower in-hospital mortality when compared with SAVR.
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50
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Dhoble A, Bhise V, Nevah MI, Balan P, Nguyen TC, Estrera AL, Smalling RW. Outcomes and readmissions after transcatheter and surgical aortic valve replacement in patients with cirrhosis: A propensity matched analysis. Catheter Cardiovasc Interv 2017; 91:90-96. [DOI: 10.1002/ccd.27232] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/16/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Abhijeet Dhoble
- Division of Cardiology; University of Texas McGovern Medical School; Houston Texas
- Memorial Herman Heart and Vascular Center, Texas Medical Center; Houston Texas
| | - Viraj Bhise
- Division of Cardiology; University of Texas McGovern Medical School; Houston Texas
- School of Public Health; University of Texas; Houston Texas
| | - Moises I. Nevah
- Memorial Herman Heart and Vascular Center, Texas Medical Center; Houston Texas
- Division of Gastroenterology, Hepatology and Nutrition; University of Texas McGovern School of Medicine; Houston Texas
| | - Prakash Balan
- Division of Cardiology; University of Texas McGovern Medical School; Houston Texas
- Memorial Herman Heart and Vascular Center, Texas Medical Center; Houston Texas
| | - Tom C. Nguyen
- Memorial Herman Heart and Vascular Center, Texas Medical Center; Houston Texas
- Department of Cardiothoracic and Vascular Surgery; University of Texas McGovern School of Medicine; Houston Texas
| | - Anthony L. Estrera
- Memorial Herman Heart and Vascular Center, Texas Medical Center; Houston Texas
- Department of Cardiothoracic and Vascular Surgery; University of Texas McGovern School of Medicine; Houston Texas
| | - Richard W. Smalling
- Division of Cardiology; University of Texas McGovern Medical School; Houston Texas
- Memorial Herman Heart and Vascular Center, Texas Medical Center; Houston Texas
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