Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery

Abstract

Objective: There are few data assessing factors, which identify patients with liver cirrhosis (LC) facing high risk for open-heart surgery. We sought to compare the Model for End-Stage Liver Disease (MELD) score, the Child-Turcotte-Pugh (CTP) classification and the European system for cardiac operative risk evaluation (EuroSCORE) for risk prediction in cirrhotic patients.

Methods: Fifty-seven consecutive patients with non-cardiac LC, who underwent open-heart surgery with the use of cardiopulmonary bypass between 1998 and 2008, were studied at our institution. Potential preoperative predictors of outcome, as well as preoperative MELD score, CTP classification and EuroSCORE were calculated. The primary study end points were all-cause in-hospital and long-term mortality.

Results: MELD score and CTP classification both differed significantly between survivors and non-survivors for in-hospital (P<0.0001) and long-term mortality (P<0.0001). Univariate predictors of in-hospital mortality were emergency surgery (odds ratio (OR), 4.9; 95% confidence interval (CI), 1.2-20.6; P=0.03), ascites (OR, 7.2; 95% CI, 2.0-25.5; P=0.002), total serum protein (OR, 0.4; 95% CI, 0.2-0.8; P=0.01), CTP class (OR, 5.5; 95% CI, 1.4-21.5; P=0.04) and MELD score (OR, 1.4; 95% CI, 1.1-1.6; P=0.001). Multivariable exact logistic regression analyses revealed MELD score (OR, 1.3; 95% CI, 1.005-1.6; P=0.04) as the only independent factor associated with in-hospital mortality. Receiver operating characteristic curve (ROC) analysis showed MELD score to be highly predictive with an optimal cut-off value of 13.5 (sensitivity: 82.0%, specificity: 78.5%) for postoperative in-hospital mortality (area under curve (AUC): 85.1 ± 0.05%) and superior compared to the CTP classification (AUC: 75.7±0.08%) and EuroSCORE (AUC: 65.9 ± 0.08%).

Conclusions: The mortality of patients with liver cirrhosis undergoing open-heart surgery progressively increases with the severity of liver dysfunction. Therefore, the MELD score most reliably identifies those cirrhotic patients who are at high risk for open-heart surgery.