Concomitant cardiac surgery and liver transplantation: an alternative approach in patients with end stage liver failure?

Perfusion. 2021 Oct;36(7):737-744. doi: 10.1177/0267659120966549. Epub 2020 Oct 23.

Abstract

Background: The results of cardiac surgery in patients with end-stage-liver-disease (ESLD) are poor. Concomitant cardiac surgery and orthotopic liver transplantation (OLT) may be an alternative treatment strategy in these patients.

Methods: Between 2001 and 2018, eight patients underwent concomitant cardiac surgery and OLT (Conc_OLT) in our institution. We analyzed their preoperative, intraoperative and postoperative data and compared them to seven high risk patients with ESLD who underwent isolated cardiac surgery (Iso_Surg).

Results: The two groups were not significantly different in terms of gender and age (Conc_OLT: 5 males, 55 ± 15 years, Iso_Surg: 4 males, 60 ± 10 years). Causes for ESLD were primary biliary cirrhosis (Conc_OLT = 1, Iso_Surg = 1), alcoholism (Conc_OLT = 2, Iso_Surg = 2), viral hepatitis (Conc_OLT = 2, Iso_Surg = 2), cryptogenic (Conc_OLT = 2, Iso_Surg = 1), ischemic (Conc_OLT = 1) and hepatocellular carcinoma (Iso_Surg = 1). Model for End-stage-Liver-Disease (MELD) Score (Conc_OLT = 14, Iso_Surg = 13) and Child-Pugh Score (Conc_OLT = 9.5, Iso_Surg = 8) were not significantly different between the two groups. Median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 9.5% (Conc_OLT) and 7.1% (Iso_Surg). Cardiac procedures undertaken were aortic valve replacement (Conc_OLT = 6, Iso_Surg = 3), coronary bypass grafting (Conc_OLT = 1,Iso_Surg = 2), tricuspid valve repair (Conc_OLT = 1), combined aortic and mitral valve replacement (Iso_Surg = 1) and excision of atrial myxoma (Iso_Surg = 1). Median length of in-hospital-stay was longer in the Conc_OLT group (73 vs. 42 days; p = 0.11). At 3 months, in-hospital mortality was 25% in the Conc_OLT group (n = 2) and lower compared to 71% observed in the Iso_Surg group (n = 5, p = 0.13).

Conclusion: Concomitant cardiac surgery and OLT is a promising alternative compared to isolated cardiac surgery in high risk patients with ESLD. Given the high operative mortality of cardiac surgery in patients with ESLD, the complex peri-operative management of these patients should be performed in an interdisciplinary team with an expert team of liver specialists involved.

Keywords: cardiac surgery; end-stage liver disease; liver transplant.

MeSH terms

  • Adult
  • Aged
  • Cardiac Surgical Procedures*
  • Coronary Artery Bypass
  • End Stage Liver Disease* / surgery
  • Heart Valve Prosthesis*
  • Humans
  • Liver Transplantation*
  • Male
  • Middle Aged
  • Retrospective Studies
  • Treatment Outcome