The Impact of Complications of Cirrhosis in Patients Undergoing Cardiac Surgery: A Propensity Matched Cohort Study

Abstract

Background: Patients with cirrhosis and concomitant coronary/valvular heart disease present a clinical dilemma. Cardiac surgeons often are reluctant to operate in this high-risk population, potentially diminishing survival/potential for liver transplant. This study aimed to identify associations between the severity of cirrhosis and post-cardiac surgical outcomes. Methods: We performed a retrospective study of propensity matched cohorts of patients undergoing cardiac surgery from APPROACH database at the University of Alberta Hospital from January 2004 to December 2014. The relationship between severity of liver disease, medical comorbidity and surgical factors on survival to hospital discharge were evaluated. Key summary: Among 60 subjects with cirrhosis, the overall mortality was 40%. Compared with non-cirrhotic patients (n=310), cirrhotics had more postoperative complications (respiratory and renal failure), longer cardiopulmonary bypass time [128 (99 - 200) vs 116 (83 - 161) minutes, p=0.02] and required more blood products during surgery (58% vs 43%, p=0.03). Cirrhotics also had longer median length of stay in ICU [5 (3 -11) vs 2 (1 - 4), p=0.00001] and were more likely to be on mechanical ventilation [2 (1 - 5) vs 1(0.5 -1.2), p=0.00001] and renal replacement therapy (15% vs 6%, p=0.02) post-operatively. After adjusting for other covariates, presence of cirrhosis [aOR: 2.2 (95%CI: 1.10 - 4.22)], increased CCI [aOR: 1.4 (95%CI: 1.18 - 1.60)] and the need for any intraoperative transfusion [aOR: 2.6 (95%CI: 1.28 - 5.04)] were independently associated with increased mortality. Conclusion: Mortality rates were significantly high in cirrhotics undergoing cardiac surgery compared to their non-cirrhotic counterparts despite having lower median MELD scores. Compared with non-cirrhotic patients, cirrhotics undergoing surgery had more postoperative complications, had a higher overall burden on preoperative illness (CCI) and required more medical services and organ support post-operatively.