Progressive hepatic and renal failure associated with low cardiac output following open-heart surgery

Characteristics and outcomes of Stanford type A aortic dissection patients with severe post-operation hyperbilirubinemia: a retrospective cohort study

BACKGROUND

Hyperbilirubinemia is one of the common complications after cardiac surgery and is associated with increased mortality. However, to the best of our knowledge, the reports on clinical significance of postoperative severe hyperbilirubinemia in Stanford type A aortic dissection (AAD) patients were limited.

METHODS

Patients who underwent surgical treatment for AAD in our center between January 2015 and December 2018 were retrospectively screened. In-hospital mortality, long-term mortality, acute kidney injury (AKI), and the requirement of continuous renal replacement therapy (CRRT) were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of these endpoints.

RESULTS

After screening, 271 patients were included in our present study. Of the included patients, 222 (81.9%) experienced postoperative AKI, and 50 (18.5%) received CRRT. The in-hospital mortality was 30.3%. The 1-year, 2-year, and 3-year cumulative mortality were 32.9, 33.9, and 35.3%, respectively. Multivariate Logistic regression analysis indicated that age (P < 0.033), AKI stage 3 (P < 0.001), the amount of blood transfusion after surgery (P = 0.019), mean arterial pressure (MAP) in the first postoperative day (P = 0.012), the use of extracorporeal membrane oxygenation (ECMO) (P = 0.02), and the peak total bilirubin (TB) concentration (P = 0.023) were independent risk factors of in-hospital mortality. The optimal cut-off value of peak TB on predicting in-hospital mortality was 121.2 μmol/L. Patients with post-operation TB ≥ 121 μmol/L was associated with worse long-term survival as well.

CONCLUSIONS

Severe post-operation hyperbilirubinemia is a common clinical situation in patients had AAD repair. In AAD patients with severe post-operation hyperbilirubinemia, older age, lower MAP, increased blood transfusion, stage 3 AKI, the use of ECMO, and the increased peak TB lead to increase in-hospital mortality.

Hepatic dysfunction after cardiac surgery in children

OBJECTIVE: The objective of this study was to analyze the incidence and significance of hepatic dysfunction after cardiac surgery in children. DESIGN: Prospective, observational study. SETTING: Pediatric intensive care unit of a university hospital. PATIENTS: The study consisted of 232 children ranging in age from newborn to 17 years with no history of liver disease. MEASUREMENTS AND MAIN RESULTS: Aspartate aminotransferase (AST), alanine aminotransferase (ALT), gammaglutamyltranspeptidase (GGT), alkaline phosphatase, total and conjugated bilirubin, blood glucose, urea, creatinine, and coagulation studies were determined at admission, at 24 and 48 hrs, and at 7 days. Hepatic dysfunction was taken as an ALT of > 100 IU/L or a moderate or high hepatic score. The statistical study included bivariate analysis and multivariate logistic regression to study the risk factors for hepatic dysfunction. Twenty-one patients (9%) showed an ALT > 100 IU/L, and 29.3% had a moderate or high hepatic score. A relationship was found between hepatic dysfunction and the type of cardiopathy (D-transposition of the great arteries and coarctation of the aorta), shock, the administration of dopamine or epinephrine, renal insufficiency, the presence of pulmonary changes (pulmonary edema, atelectasis, pulmonary hypertension, hypoxemia), hematologic disturbances (prothrombin time, kaolin-cephalin time, fibrinogen, and platelets), and the need for a greater number of transfusions of packed cells, plasma, and platelets. Compared with 7.6% of the rest of the patients (p <.001), 38% of patients with an ALT > 100 IU/L died. The hepatic score of those patients who died was 4.2 (2.3)-higher than that of the survivors at 1.5 (1.8), (p <.001). Shock and renal insufficiency were the factors most significantly related to the development of hepatic dysfunction. CONCLUSIONS: Hepatic dysfunction is an uncommon complication in children after cardiac surgery. This complication is related mainly to hemodynamic disturbances and renal insufficiency and is an indicator of poor prognosis.

Enhancing liver blood flow after cardiopulmonary bypass: the effects of dopamine and dopexamine

Liver blood flow is reduced after cardiopulmonary bypass (CPB) and both dopamine and dopexamine are used to overcome this. This study compares the effects of these agents on liver blood flow. Thirty patients undergoing elective coronary artery bypass graft surgery were randomized into three groups (n = 10 per group). Six hours after surgery baseline liver blood flow was determined by the percentage disappearance rate of indocyanine green measured by dichromatic auricular densitometery. Patients then received infusions of either: (1) placebo (dextrose 5%); (2) dopamine (4 micrograms/kg/min); (3) dopexamine (1 microgram/kg/min increasing to 2 micrograms/kg/min). One hour after infusion, liver blood flow measurements were repeated. In the dopexamine group the infusion was increased and the measurements repeated another hour later. We found that patient-specific variables and operative details were similar for all groups. Postoperative cardiac index and heart rate were increased significantly by dopamine (cardiac index 2.82 +/- 0.46 l/m/m2 vs 3.28 +/- 0.67 l/m/m2: p < 0.001 and heart rate 87.5 +/- 13.2 vs 96 +/- 16: p < 0.05) and dopexamine at 2 micrograms/kg/min (cardiac index 2.71 +/- 0.53 l/m/m2 vs 3.45 +/- 0.67 l/m/m2: p < 0.05 and heart rate 89.0 +/- 18.9 vs 107.4 +/- 13.6: p < 0.001) compared to placebo (cardiac index 2.97 +/- 0.8 l/m/m2 vs 3.18 +/- 0.9 l/m/m2: p > 0.05 and heart rate 77.2 +/- 7.4 vs 77.3 +/- 8: p > 0.05) despite similar atrial and systemic arterial pressures. The disappearance rate of indocyanine green was not altered during infusion of placebo group (9.0 +/- 3.2%/min vs 7.9 +/- 3.0%/min: p > 0.05) or dopexamine at 1 microgram/kg/min (9.7 +/- 3.1%/min vs 11.2 +/- 4.1%/min: p > 0.05). The disappearance rate was increased with dopamine (6.7 +/- 3.7%/min vs 11.8 +/- 3.0%/min: p < 0.05) and dopexamine 2 micrograms/kg/min (9.7 +/- 3.1%/min vs 13.5 +/- 3.2%/min: p < 0.05). This indicates a 76% increase in liver blood flow with dopamine and a 38% increase with dopexamine. We conclude that dopamine 4 micrograms/kg/min and dopexamine 2 micrograms/kg/min increase liver blood flow, although this may, in part, be related to an increase in cardiac output. Dopexamine shows no advantage over dopamine in enhancing liver blood flow after CPB.

The validation of auricular densitometry for indocyanine green clearance measurement of hepatic blood flow during and after cardiopulmonary bypass in children

The clinical measurement of hepatic perfusion is complicated by a dual blood supply and the invasive nature of the majority of techniques available. The aim of this study was to validate indocyanine green clearance and noninvasive auricular densitometry as a measure of hepatic perfusion in the context of paediatric cardiac surgery. The effects of different dye concentrations on densitometer recording were assessed in vitro and found to have a linear relationship. Similarly, variations in haematocrit, within the range 21-47%, also had little effect on accuracy. Comparison of densitometry and direct blood sampling with plasma spectrophotometry in six postoperative, normothermic children showed no significant difference between the noninvasive and invasive techniques (r = 0.968; p > 0.05, t-test). Comparison in 10 hypothermic children during cardiopulmonary bypass also showed no significant difference between the two methods, provided that no further cooling or rewarming took place (r = 0.83; p > 0.05, Wilcoxon test). Noninvasive auricular densitometry can, therefore, provide a reliable assessment of hepatic perfusion in children undergoing cardiac surgery.

The effects of congenital heart disease and cardiac surgery on liver blood flow in children

Children with congenital heart disease may have some degree of hepatic impairment, with further impairment developing shortly after surgical correction of the cardiac defect. The redistribution of organ blood flow that occurs during cardiopulmonary bypass implicates ischaemia as one of the principal causes of injury. The aim of this study was to measure liver blood flow in children with congenital heart disease and to determine both the effects of cardiopulmonary bypass and the consequences of corrective surgery. Indocyanine green clearance and auricular densitometry, were used in 31 children. In 83% we demonstrated a reduced liver blood flow, with a mean percentage disappearance rate (PDR) of 12.9% (SEM +/- 1.2). This finding was unrelated to the patient's age, the type of congenital heart defect or the presence or absence of cyanosis. During cardiopulmonary bypass, hepatic perfusion was further reduced in 77% of children, by an average of 67%, out of proportion with the iatrogenic reduction in total body flow. Six hours after surgery, liver blood flow had increased significantly above preoperative levels (p < 0.001; t-test) to approximately normal values with a mean PDR of 20.4% (SEM +/- 1.5).

Acute hepatic failure after open-heart surgery in children

Acute hepatic failure (AHF) combined with acute renal failure (ARF) is a well-known complication of open-heart surgery in adults. The occurrence of this complication in two children after open-heart surgery for correction of congenital heart disease is reported. Hypotension occurred during the operation and was treated by catecholamine vasopressors. AHF set in during the postoperative course; it was manifested by impaired consciousness, hypoglycemia, hyperbilirubinemia, hyperammonemia, elevated liver enzymes and prolongation of the prothrombin time with failure of hemostasis. ARF also developed in both children. One of the patients survived the acute episode of hepatic failure. The importance of early diagnosis, routine close monitoring, and appropriate selection of vasopressors is emphasized.

Jaundice after open heart surgery: a prospective study

One hundred and fifty four consecutive adult patients having cardiac surgery for a variety of cardiac lesions were evaluated prospectively for postoperative jaundice, those with a raised preoperative serum bilirubin concentration (greater than 34 mumol/l or 2 mg/100 ml) being excluded. The incidence of early postoperative jaundice, as defined by a serum bilirubin concentration of 50 mumol/l (3.0 mg/100 ml) or greater, was 23.4%. The jaundice was mild (bilirubin concentration 51-100 mumol/l (3.0-6.0 mg/100 ml] in 26 patients (16.9%) and moderate to severe (greater than 100 mumol/l (6.0 mg/100 ml] in 10 patients (6.5%). Important contributing factors were the preoperative severity of right heart failure (raised right atrial pressure at heart catheterisation) and hypotension or hypoxaemia and the amount of blood transfused during or shortly after surgery. Age, sex, underlying cardiac lesion, whether halothane was used, operative procedure, duration of cardiopulmonary bypass, and presence or absence of hepatitis B surface antigen were not predictive of postoperative jaundice.

Incidence and prognostic importance of jaundice after cardiopulmonary bypass surgery

In a prospective study of 248 consecutive patients undergoing cardiopulmonary bypass surgery, early postoperative "post-pump" jaundice (PPJ) developed in 49 (20%). Development of PPJ was strongly associated with a bad outcome; 25% of jaundiced patients and 1% of non-jaundiced patients died in the postoperative period. The jaundice was a conjugated hyperbilirubinaemia, and was detectable in 48 out of 49 patients by postoperative day 2. Hypotension, hypoxia, and hypothermia ("shocked liver") were not associated with the development of PPJ, nor was evidence of haemolysis or heart-failure. Although PPJ was significantly associated with multiple valve replacement, higher transfusion requirements, and longer cardiopulmonary bypass time, it also occurred in patients undergoing uncomplicated operations. It is suggested that PPJ is caused by a defect in hepatic excretion of bilirubin.

Rheological and biochemical changes in open heart surgery with extracorporeal circulation and moderate hypothermia

The plasma enzymes, glucose, urea nitrogen, total and conjugated bilirubin, osmolality, acid--base balance and rheological data have been studied in a group of patients who underwent open heart surgery to replace the stenotic or insufficient aortic valve. The aim of this study was to assess our operative conditions and to compare results with those obtained by other authors.

Jaundice following open-heart surgery

Singh, H. M., and Baker, J. T. (1974). Thorax, 29, 68-74. Jaundice following open-heart surgery. A study was made into the factors influencing the onset of jaundice in 102 patients undergoing valve replacement during cardiopulmonary bypass. Postoperative jaundice appeared to be correlated with double valve replacement, the co-existence of an uncorrected valvular lesion, length of perfusion and myocardial ischaemia times, and also the age of the patient. Factors appearing not to be correlated with the onset of jaundice included preoperative pulmonary artery pressure, cardiac index, parameters of preoperative renal and hepatic function, and the amount of blood used during bypass. The biochemical features of the jaundice seemed to follow a pattern not previously recognized in this context, with sometimes considerably raised bilirubin levels in association with virtually normal levels of transaminases and alkaline phosphatase.