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Cardiac Surgery Risks in Liver Dysfunction

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Liver Diseases

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Abstract

The incidence of chronic liver diseases and cirrhosis is steadily increasing. It is therefore common that patients with advanced liver dysfunction are addressed for cardiac surgery interventions. Risk score models specifically developed for cardiac surgery to assess a patient’s surgical candidacy based on the potential unfavourable outcome fail to include all major factors that may render patients at higher risk for surgery. Advanced liver dysfunction is among the excluded factors and for a cardiac surgeon it is problematic to distinguish patients who may benefit from cardiac surgery from those whose perioperative risk exceeds benefit. Consequently, for patients with advanced liver dysfunction, the operative benefit needs to be carefully weighted after a specific assessment and the therapeutic management adapted to the particular clinical picture of the individual patient. The aims of this chapter are to reveal the impact of the pathophysiological changes induced by advanced liver dysfunction on the surgical and anaesthetic outcomes in cardiac surgery and to outline the particular aspects of the pre, intra and postoperative management used to optimize the outcome in this group of patients.

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Author information

Authors and Affiliations

  1. Cardiovascular Institute, Iasi, Romania

    Grigore Tinica & Raluca Ozana Chistol

  2. Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

    Grigore Tinica, Cristina Furnica & Raluca Ozana Chistol

  3. Institute of Forensic Medicine, Iasi, Romania

    Cristina Furnica

Authors
  1. Grigore Tinica
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  2. Cristina Furnica
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  3. Raluca Ozana Chistol
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Editor information

Editors and Affiliations

  1. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Florentina Radu-Ionita

  2. New Jersey Medical School, Rutgers University New Jersey Medical School, Newark, NJ, USA

    Nikolaos T. Pyrsopoulos

  3. Carol Davila University of Medicine and Pharmacy, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Mariana Jinga

  4. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Ion C. Tintoiu

  5. Medical Radiation Sciences, Curtin University, Perth, WA, Australia

    Zhonghua Sun

  6. “Prof. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Bucharest, Romania

    Ecaterina Bontas

Self Study

Self Study

1.1 Questions

  1. 1.

    Which statement is true?

    1. (a)

      Cardiac surgery risk scores (STS, EuroSCORE II) correctly estimate mortality risk in cirrhotic patients.

    2. (b)

      Cardiopulmonary bypass has no impact on liver function.

    3. (c)

      In CTP class A patients the pharmacokinetics of anaesthetic drugs is almost unchanged.

    4. (d)

      Advanced liver dysfunction is an absolute contraindication to cardiac surgery.

  2. 2.

    Which statement is true?

    1. (a)

      Non cirrhotic patients register no changes of liver function tests in the postoperative period.

    2. (b)

      Haemorrhagic complications are most common cause of postoperative mortality in cirrhotic patients undergoing cardiac surgery.

    3. (c)

      TAVI is not indicated in CTP class C patients.

    4. (d)

      Fresh frozen plasma (FFP) can be used to correct coagulopathies in the postoperative period.

1.2 Answers

  1. 1.

    Which statement is true?

    1. (a)

      EuroSCORE II system includes a limited number of patient related factors like age, gender, renal impairment, extracardiac arteriopathy, poor mobility, previous cardiac surgery, chronic lung disease, active endocarditis, critical preoperative state, diabetes on insulin, and omits all parameters relevant for liver function. STS on the other hand, includes liver disease among the evaluated parameters as a binary selection (Yes or No) irrespective to the type and severity of the disease

    2. (b)

      Hepatic dysfunction secondary to CPB is due to microembolism, free radicals generation, inadequate tissue perfusion, dilutional anaemia and haemodynamic changes and activation of multiple humoral (coagulation, complement, kinin-kallikrein, cytokines, fibrinolysis) and cellular (platelets, neutrophils, endothelial cells) systems.

    3. (c)

      CORRECT ANSWER. In well-compensated patients with close to normal liver function (CTP class A), the pharmacokinetics of anaesthetic drugs is almost unchanged. The more serious the cirrhosis is (portal hypertension, hepatocellular insufficiency), the more important and difficult to predict are the pharmacological changes.

    4. (d)

      CTP class A patients can safely undergo cardiac surgery. In class B, open cardiac surgery is possible, preferably off pump and after adequate preoperative preparation.

  2. 2.

    Which statement is true?

    1. (a)

      In general population, transient elevation of bilirubin and hepatic enzymes is noticed in the early postoperative period, but in cirrhotic patients decompensation can occur.

    2. (b)

      The cirrhotic patient carries a higher risk of prolonged hospitalization in the intensive care unit and the most common cause of perioperative mortality is sepsis. Bacteraemia is frequent, mostly secondary to bacterial translocation correlated with deficient immune response. At the slightest suspicion, an empiric antibiotherapy should be quickly initiated.

    3. (c)

      In CTP class C patients, open cardiac surgery is contraindicated and endovascular treatment (TAVI) should be considered instead if technically possible.

    4. (d)

      CORRECT ANSWER. Fresh frozen plasma (FFP) can be used to correct identified coagulopathies while monitoring the central venous pressure to avoid fluid overload. If FFP is not sufficient or not indicated (fluid overload), cryoprecipitate or desmopressin represent alternative methods.

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Tinica, G., Furnica, C., Chistol, R.O. (2020). Cardiac Surgery Risks in Liver Dysfunction. In: Radu-Ionita, F., Pyrsopoulos, N., Jinga, M., Tintoiu, I., Sun, Z., Bontas, E. (eds) Liver Diseases. Springer, Cham. https://doi.org/10.1007/978-3-030-24432-3_73

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  • DOI: https://doi.org/10.1007/978-3-030-24432-3_73

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-24431-6

  • Online ISBN: 978-3-030-24432-3

  • eBook Packages: MedicineMedicine (R0)

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