Outcomes of Simultaneous Liver Transplantation and Elective Cardiac Surgical Procedures

Strategy and Outcomes of Cardiac Surgery in Patients With Cirrhosis: Comprehensive Approach With Liver Transplant Program

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.

Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions

Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.

Anesthetic Considerations for Patients With Mitral Stenosis Undergoing Orthotopic Liver Transplant

A 70-year-old male presented for an orthotopic liver transplant (OLT) with co-existing moderate-severe mitral valve stenosis. The hemodynamic goals of managing mitral stenosis posed a significant additional challenge to this patient's care. Intraoperative transesophageal echocardiography (TEE) was critical in guiding volume status and resuscitation. In addition, the patient's valvulopathy guided our vasoactive medication selection and arrhythmia prevention. In this article, we describe the multidisciplinary discussions regarding preoperative valvular intervention as well as the intraoperative techniques used to preserve cardiac output while avoiding coagulopathy and arrhythmias. We discuss the pathophysiology of valvular disease in the context of liver failure and the guidelines by which this disease process is classified. In addition, we discuss the benefits and limitations of intraoperative TEE in evaluating this unique physiology.

Simultaneous Live Donor Liver Transplantation, Aortic Valve Replacement, and Atrial Septal Defect Repair in a Patient With End Stage Liver Disease: A Case Report

Valvular heart disease creates an important barrier for orthotopic liver transplantation in patients with end-stage liver disease and increases mortality. Selection of the appropriate surgical scheme and adequate postoperative management can be lifesaving in these cases. This study presents a 32-year-old man diagnosed with hepatitis C-associated cirrhosis and severe aortic regurgitation due to subacute bacterial endocarditis. Initially, simultaneous aortic valve replacement (AVR) and live donor liver transplantation (LDLT) was planned. However, intraoperative transesophageal echocardiography revealed an additional atrial septal defect (ASD) and AVR, ASD repair, and LDLT surgery were performed. During the 2-year follow-up period, there were no early or late complications. To the best of our knowledge, this is the first patient to have simultaneous AVR, ASD repair, and LDLT surgery. Additionally, the present case is also unique in being the first person in the Republic of Azerbaijan to undergo concomitant cardiac surgery and LDLT.

Evaluation of liver transplant candidates with non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is anticipated to become the leading indication for liver transplantation (LT) in the United States in the near future. LT is indicated in patients with NASH-related cirrhosis who have medically refractory hepatic decompensation, synthetic dysfunction, and hepatocellular carcinoma (HCC) meeting certain criteria. The objective of LT evaluation is to determine which patient will derive the most benefit from LT with the least risk, thus maximizing the societal benefits of a limited resource. LT evaluation is a multidisciplinary undertaking involving several specialists, assessment tools, and diagnostic testing. Although the steps involved in LT evaluation are relatively similar across different liver diseases, patients with NASH-related cirrhosis have unique demographic and clinical features that affect transplant outcomes and influence their LT evaluation. LT candidates with NASH should be assessed for metabolic syndrome and obesity, malnutrition and sarcopenia, frailty, and cardiovascular disease. Interventions that treat cardiometabolic co-morbidities and improve patients' nutrition and functionality should be considered in order to improve patient outcomes in the waitlist and after LT.

Combined cardiac surgery procedures and liver transplant: a single-center experience

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.

Combined off pump coronary artery bypass graft and liver transplant

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.

Cardiac evaluation of the kidney or liver transplant candidate

PURPOSE OF REVIEW

As the field of transplant has advanced, cardiac events have become the leading cause of morbidity and mortality after liver and kidney transplantation ahead of graft failure and infection. This trend has been bolstered by the transplantation of older and sicker patients who have a higher burden of cardiovascular risk factors, accentuating the need to determine which patients should undergo more extensive cardiac evaluation prior to transplantation.

RECENT FINDINGS

Computed tomography coronary angiography with or without coronary artery calcium scoring is now preferred over stress imaging in most transplant candidates for assessment of coronary artery disease. Assessment of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended, particularly in liver transplant candidates who are at high risk of cirrhotic cardiomyopathy, for which new diagnostic criteria were recently published in 2019.

SUMMARY

Cardiac evaluation of liver and kidney transplant candidates requires a global assessment for both short and long-term risk for cardiac events. Imaging of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended. Risk stratification should consider both the anatomic and functional consequences of coronary artery disease in transplant candidates.

VIDEO ABSTRACT

http://links.lww.com/MOT/A27.

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

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.

Combined Cardiothoracic Surgery and Liver Transplantation Versus Isolated Liver Transplantation

OBJECTIVE

Combined cardiothoracic surgery and liver transplantation (cCSLT) recently increasingly has been used. Despite that, liver transplant immediately after cardiothoracic surgery has not been well-characterized. The authors aimed to compare perioperative management and postoperative outcomes between patients undergoing cCSLT and isolated liver transplantation (iLT).

DESIGN

A retrospective study.

SETTING

University tertiary medical center.

PARTICIPANTS

Twenty-five cCSLT patients and 1091 iLT patients at a single institution from 2010 to 2017.

INTERVENTIONS

Twenty-five cCSLT patients were compared with 100 randomly selected and 100 propensity-matched iLT patients.

MEASUREMENTS AND MAIN RESULTS

All cCSLT patients underwent comprehensive preoperative evaluation by a multidisciplinary team. Of 25 cardiothoracic surgeries, heart transplant (n = 9) was most common, followed by coronary artery bypass grafting (n = 5) and lung transplant (n = 3). Intraoperative management of cCSLT was provided by 2 separate teams, one for cardiothoracic surgery and one for liver transplantation. Patients undergoing cCSLT often required cardiopulmonary bypass, an intra-aortic balloon pump, extracorporeal membrane oxygenation, or cardiac pharmacologic therapies and, additionally, needed more interventions including antifibrinolytic administration, venovenous bypass, massive blood transfusion, and platelet transfusions compared with iLT patients. Ninety-day survival rates were similar in the cCSLT (100%) and iLT groups (random iLT 87% and matched iLT 93%, log-rank test p = 0.089).

CONCLUSIONS

Despite having end-stage liver disease and advanced cardiothoracic disorders and experiencing a complex intraoperative course, cCSLT patients had comparable 90-day survival to iLT patients. Comprehensive planning before transplant, optimal patient/donor selection, the multiple-team model, and meticulous intraoperative management are critical to the success of cCSLT.

Safety and Outcomes of Combined Liver Transplantation and Cardiac Surgery in Cirrhosis

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.

Impact of Having a Planned Additional Operation at Time of Liver Transplant on Graft and Patient Outcomes

Advances in liver transplantation (LT) have allowed for expanded indications and increased surgical complexity. In select cases, additional surgery may be performed at time of LT rather than prior to LT due to the significant risks associated with advanced liver disease. We retrospectively studied the characteristics and outcomes of patients who underwent an additional planned abdominal or cardiac operation at time of LT between 2011–2019. An additional operation (LT+) was defined as a planned operation performed under the same anesthetic as the LT but not directly related to the LT. In total, 547 patients were included in the study, of which 20 underwent LT+ (4%). Additional operations included 10 gastrointestinal, 5 splenic, 3 cardiac, and 2 other abdominal operations. Baseline characteristics between LT and LT+ groups were similar. The median total operating time was significantly longer in LT+ compared to LT only (451 vs. 355 min, p = 0.002). Graft and patient survival, intraoperative blood loss, transfusion of blood products, length of hospital stay, and post-operative complications were not significantly different between groups. In carefully selected patients undergoing LT, certain additional operations performed at the same time appear to be safe with equivalent short-term outcomes and liver graft survival as those undergoing LT alone

Liver transplantation and cardiac illness: Current evidences and future directions

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.

Preoperative cardiac assessment in liver transplant candidates

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.

The impact of cirrhosis in patients undergoing cardiac surgery: a retrospective observational cohort study

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.

Transfemoral Transcatheter Aortic Valve Replacement for Mixed Aortic Valve Disease in Child’s Class C Liver Disease Prior to Orthotopic Liver Transplantation

The American Association for the Study of Liver Diseases practice guidelines list severe cardiac disease as a contraindication to liver transplantation. Transcatheter aortic valve replacement has been shown to decrease all-cause mortality in patients with severe aortic stenosis who are not considered candidates for surgical aortic valve replacement. We report our experience of liver transplantation in a patient with severe aortic stenosis and moderate aortic insufficiency who underwent transcatheter aortic valve replacement with Child-Pugh Class C disease at a Model For End-Stage Liver Disease score of 29. The patient had a difficult post procedure course that was successfully medically managed. After liver transplantation the patient was discharged to home on postoperative day 11. The combination of cardiac disease and end stage liver disease is challenging but these patients can have a successful outcome despite very severe illness.

Short-term independent mortality risk factors in patients with cirrhosis undergoing cardiac surgery

OBJECTIVES

Cirrhosis represents a serious risk in patients undergoing cardiac surgery. Several preoperative factors identify cirrhotic patients as high risk for cardiac surgery; however, a patient's preoperative status may be modified by surgical intervention and, as yet, no independent postoperative mortality risk factors have been identified in this setting. The objective of this study was to identify preoperative and postoperative mortality risk factors and the scores that are the best predictors of short-term risk.

METHODS

Fifty-eight consecutive cirrhotic patients requiring cardiac surgery between January 2004 and January 2009 were prospectively studied at our institution. Forty-two (72%) patients were operated on for valve replacement, 9 (16%) for a CABG and 7 (12%) for both (CABG and valve replacement). Thirty-four (58%) patients were classified as Child-Turcotte-Pugh class A, 21 (36%) as class B and 3 (5%) as class C. We evaluated the variables that are usually measured on admission and during the first 24 h of the postoperative period together with potential operative predictors of outcome, such as cardiac surgery scores (Parsonnet, EuroSCORE), liver scores (Child-Turcotte-Pugh, model for end-stage liver disease, United Kingdom end-stage liver disease score) and ICU scores (acute physiology and chronic health evaluation II and III, simplified acute physiology score II and III, sequential organ failure assessment).

RESULTS

Seven patients (12%) died in-hospital, of whom 5 were Child-Turcotte-Pugh class B and 2 class C. Comparing survivors vs non-survivors, univariate analysis revealed that variables associated with short-term outcome were international normalized ratio (1.5 ± 0.24 vs 2.2 ± 0.11, P < 0.0001), presurgery platelet count (171 ± 87 vs 113 ± 52 l nl(-1), P = 0.031), presurgery haemoglobin count (11.8 ± 1.8 vs 10.2 ± 1.4 g dl(-1), P = 0.021), total need for erythrocyte concentrates (2 ± 3.4 vs 8.5 ± 8 units, P < 0.0001), PaO(2)/FiO(2) at 12 h after ICU admission (327 ± 84 vs 257 ± 78, P = 0.04), initial central venous pressure (11 ± 3 vs 16 ± 4 mmHg, P = 0.02) and arterial blood lactate concentration 24 h after admission (1.8 ± 0.5 vs 2.5 ± 1.3 mmol l(-1), P = 0.019). Multivariate analysis identified initial central venous pressure as the only independent factor associated with short-term outcome (P = 0.027). The receiver operating characteristic curve showed that the model for end-stage Liver disease score had a better predictive value for short-term outcome than other scores (AUC: 90.5 ± 4.4%; sensitivity: 85.7%; specificity: 83.7%), although simplified acute physiology score III was acceptable.

CONCLUSIONS

We conclude that central venous pressure could be a valuable predictor of short-term outcome in patients with cirrhosis undergoing cardiac surgery. The model for end-stage liver disease score is the best predictor of cirrhotic patients who are at high risk for cardiac surgery. Sequential organ failure assessment and simplified acute physiology score III are also valuable predictors.

Simultaneous nephrectomy and coronary artery bypass grafting through extended sternotomy

Background

The advances in surgical techniques, resuscitation and anesthesiology support over the last years have allowed simultaneous thoracic and abdominal operations to be made for cancer and concomitant severe heart vessel disease relieving the patient from several diseases simultaneously and achieving long lasting remission or cure.

Clinical case

A simultaneous nephrectomy and coronary artery bypass grafting procedure through extended sternotomy is reported. A 63-year-old man with severe coronary artery disease was found to have renal carcinoma.

Diagnosis

Postoperative pathological investigation of the tumor revealed the presence of renal cell carcinoma pT3a N0 M0, G2. Coronarography revealed advanced three-vessel coronary artery disease.

Treatment

We successfully performed a simultaneous curative surgery for renal carcinoma and coronary artery bypass graft surgery under cardiopulmonary bypass using a novel technique of extended sternotomy. Simultaneous surgery thus appears to be a beneficial and safe approach for the treatment of coronary artery disease and resectable renal cancer in carefully selected patients.