Antithrombin III Is Associated With Acute Liver Failure in Patients With End-Stage Heart Failure Undergoing Mechanical Circulatory Support

J Thorac Cardiovasc Surg. 2017 Jun;153(6):1374-1382. doi: 10.1016/j.jtcvs.2017.01.053. Epub 2017 Feb 9.


Objective: There are few data on the role of liver dysfunction in patients with end-stage heart failure supported by mechanical circulatory support. The aim of our study was to investigate predictors for acute liver failure in patients with end-stage heart failure undergoing mechanical circulatory support.

Methods: A consecutive 164 patients with heart failure with New York Heart Association class IV undergoing mechanical circulatory support were investigated for acute liver failure using the King's College criteria. Clinical characteristics of heart failure together with hemodynamic and laboratory values were analyzed by logistic regression.

Results: A total of 45 patients (27.4%) with heart failure developed subsequent acute liver failure with a hospital mortality of 88.9%. Duration of heart failure, cause, cardiopulmonary resuscitation, use of vasopressors, central venous pressure, pulmonary capillary wedge pressure, pulmonary pulsatility index, cardiac index, and transaminases were not significantly associated with acute liver failure. Repeated decompensation, atrial fibrillation (P < .001) and the use of inotropes (P = .007), mean arterial (P = .005) and pulmonary pressures (P = .042), cholinesterase, international normalized ratio, bilirubin, lactate, and pH (P < .001) were predictive of acute liver failure in univariate analysis only. In multivariable analysis, decreased antithrombin III was the strongest single measurement indicating acute liver failure (relative risk per %, 0.84; 95% confidence interval, 0.77-0.93; P = .001) and remained an independent predictor when adjustment for the Model for End-Stage Liver Disease score was performed (relative risk per %, 0.89; 95% confidence interval, 0.80-0.99; P = .031). Antithrombin III less than 59.5% was identified as a cutoff value to predict acute liver failure with a corresponding sensitivity of 81% and specificity of 87%.

Conclusions: In addition to the Model for End-Stage Liver Disease score, decreased antithrombin III activity tends to be superior in predicting acute liver failure compared with traditionally thought predictors. Antithrombin III measurement may help to identify patients more precisely who are developing acute liver failure during mechanical circulatory support.

Keywords: acute liver failure; cardiogenic shock; extracorporeal membrane oxygenation; mechanical circulatory support.

Publication types

  • Video-Audio Media

MeSH terms

  • Adult
  • Aged
  • Antithrombin III / metabolism*
  • Biomarkers / blood
  • Extracorporeal Membrane Oxygenation / adverse effects*
  • Extracorporeal Membrane Oxygenation / mortality
  • Female
  • Heart Failure / blood
  • Heart Failure / mortality
  • Heart Failure / physiopathology
  • Heart Failure / therapy*
  • Hemodynamics*
  • Hospital Mortality
  • Humans
  • Liver Failure, Acute / blood*
  • Liver Failure, Acute / diagnosis
  • Liver Failure, Acute / mortality
  • Liver Failure, Acute / physiopathology
  • Liver Function Tests
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Retrospective Studies
  • Risk Factors
  • Shock, Cardiogenic / blood
  • Shock, Cardiogenic / mortality
  • Shock, Cardiogenic / physiopathology
  • Shock, Cardiogenic / therapy*
  • Time Factors
  • Treatment Outcome


  • Biomarkers
  • SERPINC1 protein, human
  • Antithrombin III