58 Review Article

Impact of Hepatic Cirrhosis on Outcome in

Adult Cardiac Surgery
Ioannis Dimarakis1 Stuart Grant1 Rebecca Corless2 Theodore Velissaris3 Martin Prince4
Ben Bridgewater1 George Asimakopoulos5

1 Department of Cardiothoracic Surgery, University Hospital South Address for correspondence Ioannis Dimarakis, MD, PhD, DIC, MRCS,
Manchester, Manchester, United Kingdom Department of Cardiothoracic Surgery, University Hospital South
2 Department of Clinical Oncology Research, University Hospital South Manchester, Southmoor Road, Manchester M23 9LT, United Kingdom
Manchester, Manchester, United Kingdom (e-mail: jdimarakis@nhs.net).
3 Department of Cardiothoracic Surgery, Manchester Royal Infirmary,
Manchester, United Kingdom
4 Department of Gastroenterology, Manchester Royal Infirmary,

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Manchester, United Kingdom
5 Department of Cardiac Surgery, Bristol Heart Institute, University
Hospitals Bristol, Bristol, United Kingdom

Thorac Cardiovasc Surg 2015;63:58–66.

Abstract Increasing prevalence of hepatic disease is likely to translate in a growing number of

patients with significant hepatic disease requiring cardiac surgery. Available cardiac risk
stratification models do not address the risk associated with hepatic disease. However,
weighted mean mortality rates based on previous studies of cardiac surgery in patients
with hepatic disease demonstrate operative mortality rates that range from 9.88%
Keywords (standard deviation [SD] 9.69) for patients in Child–Turcotte–Pugh (CTP) class A
► liver diseases/cirrhosis cirrhosis to 69.23% (SD 28.55) for patients with CTP class C cirrhosis. This review
► risk comprehensively appraises the pathophysiology of hepatic disease, reported clinical
► outcomes outcomes and considerations for risk stratification.

Introduction
Advances in operative techniques along with improve-
ments in intensive care management and an increased
focus on clinical governance have improved outcomes
following cardiac surgery over recent years despite an
overall increase in patient risk profile. 1–3 Patients with
hepatic impairment who require cardiac surgery repre-
sent a particularly challenging group of patients as they
are at a greater risk of both 4 anesthetic and surgical
complications.
Although the prevalence of major causes of chronic
hepatic disease has remained stable, obesity-related non-
alcoholic fatty liver disease (NAFLD) has increased steadily,
along with the prevalence of metabolic conditions.5 Given
the rising prevalence of hepatic disease, it is inevitable that
the number of patients with hepatic disease who are
referred for cardiac surgery will also increase. More pa-
tients with end-stage hepatic disease may also be referred
for cardiac surgery as the identification and treatment of
coronary artery disease before liver transplantation may
potentially contribute to reduction of posttransplant
mortality. 6
Several features of hepatic disease make cardiac surgery
particularly high risk for this group of patients. Rates of
morbidity and mortality have been found to be high in the
majority of studies of cardiac surgery in patients with hepatic
disease. It is therefore important to establish appropriate risk
stratification in addition to optimal surgical and anesthetic
management strategies for patients with hepatic disease
undergoing cardiac surgery.

received © 2015 Georg Thieme Verlag KG DOI http://dx.doi.org/

April 21, 2014 Stuttgart · New York 10.1055/s-0034-1389084.
accepted after revision ISSN 0171-6425.
July 4, 2014
published online
October 7, 2014
 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery
Methodology
Electronic searches were performed using Ovid Medline and
EMBASE from their date of inception to April 2013. To achieve
the maximum sensitivity of the search strategy and identify
all studies, we combined “thoracic surgery” or “cardiac
surgical procedures” or “cardiac surgery” or “heart surgery”
as Medical Subject Headings (MeSH) terms or keywords with
“liver diseases” or “liver disease/dysfunction/cirrhosis” as
MeSH terms or keywords. All relevant articles identified
were assessed with application of predefined selection crite-
ria. Studies relating to transplantation or pediatric cardiac
surgery were excluded. The reference lists for retrieved
articles were reviewed to identify any additional potentially
relevant studies. To compare outcomes between patients
with different classes of hepatic disease weighted mean
mortality rates and standard deviations were calculated.
Pathophysiologic Effects of Cirrhosis
The three most common causes of chronic hepatic disease are
NAFLD, alcoholic liver disease, and chronic hepatitis C infec-
tion. Other causes of chronic hepatic disease include primary
biliary cirrhosis, autoimmune hepatitis, and inherited meta-
bolic disorders. These processes all result in hepatocellular
necrosis and cirrhosis, which is anatomically defined as a
diffuse process with fibrosis and nodule formation.
The major clinical consequences of cirrhosis are impaired
hepatocyte function and increased intrahepatic resistance (por-
tal hypertension). Cirrhosis is responsible for a decrease in portal
vascular radius, producing a dramatic increase in portal vascular
resistance. The efforts to counteract the increase in portal
pressure causes up to 90% of the portal flow to be re-directed
Fig. 1 An overview of renal and circulatory pathophysiologic events occurring during the natural history of cirrhosis (adapted from Solà and
Ginès). 66
Dimarakis et al. 59
through portosystemic collaterals back to the heart. This results
in enlargement of these vessels known as varices.7
The “peripheral arterial vasodilation hypothesis” states
that splanchnic arterial vasodilation initiates the pathophys-
iologic circulatory as well as renal abnormalities that charac-
terize cirrhosis.8 Nitric oxide, carbon monoxide, and
endogenous cannabinoids are the main vasodilators respon-
sible for the splanchnic arterial vasodilation seen in cirrhosis.
Associated reduction in systemic vascular resistance and
increased sympathetic nervous activity initially lead to the
development of a hyperdynamic circulatory state with in-
creased cardiac output and heart rate. With disease progres-
sion and worsening, splanchnic arterial vasodilation
hypotension is seen as a sequel of reduced central and
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pulmonary blood volumes. Intrinsic cirrhosis-related cardio-
myopathy is also implicated in further myocardial dysfunc-
tion and reduction of cardiac output. The triggered
baroreceptor-mediated stimulation of the sympathetic ner-
vous system, renin–angiotensin system, and antidiuretic
hormone lead to renal sodium and water retention. Ascites
and hepatorenal syndrome are the late manifestations of this
cascade (►Fig. 1). Hepatorenal syndrome constitutes a “func-
tional” form of prerenal failure and two subtypes have been
described distinguished by the speed of onset of renal failure.9
Cirrhotic cardiomyopathy has been well described as chron-
ic cardiac dysfunction leading to blunted contractile respon-
siveness to stress and/or altered diastolic relaxation with
electrophysiological abnormalities.10 When undergoing pre-
operative assessment, the ischemic as well as alcoholic nature
of any seen cardiomyopathy should also be considered.
Beyond reduction of lung volumes secondary to increased
intra-abdominal pressure or development of cirrhotic hydro-
thorax, two distinct pulmonary syndromes have been
Thoracic and Cardiovascular Surgeon Vol. 63 No. 1/2015
60 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery
described in advanced disease stages. The hepatopulmonary
syndrome is characterized by dilatation of capillaries near
alveolar areas and intrapulmonary shunting and is reversible.
Portopulmonary hypertension is similar to primary pulmo-
nary hypertension and is largely irreversible.11
Coagulation Abnormalities in Patients with
Cirrhosis
Conventional medical teaching has linked cirrhosis with an
increased bleeding tendency as the production as well as
degradation site of many proteins involved in the coagulation
cascade is performed within the liver. It has become increas-
ingly understood that in cirrhotic patients, the hemostatic
balance may tip toward both a hypo- or hypercoagulable
state.12,13 An evolving concept of rebalancing of the hemostatic
system at the level of primary and secondary hemostases, as
well as the fibrinolytic system supports this concept.14 At the
level of primary hemostasis thrombocytopenia and platelet
function defects may be counterbalanced by elevated levels of
von Willebrand factor and decreased levels of ADAMTS-13. At
the level of secondary hemostasis, the observed low levels of
coagulation factors II, V, VII, IX, X, and XI, vitamin K deficiency,
and dysfibrinogenemia may be counterbalanced by elevated
levels of factor VIII, and decreased levels of protein C, protein S,
antithrombin, α2-macroglobulin, and heparin cofactor II. Fi-
nally, at the fibrinolytic level elevated tissue plasminogen
activator (tPA) and low levels of α2-antiplasmin, factor XIII,
and thrombin-activatable fibrinolysis inhibitor (TAFI) may be
counterbalanced by low levels of plasminogen. This “balance”
explains why spontaneous nonvariceal bleeding is rare.
The fact that the coagulation pathway interactions take
place in parallel may explain the limitation of routine labora-
tory assessment of coagulation in detecting patients at high
risk of perioperative bleeding in patients with hepatic disease.
An example of the complexity of underlying pathophysiologic
mechanisms is thrombocytopenia associated with hepatic
disease. In addition to reduced production of thrombopoietin
secondary to impaired hepatic function, increased thrombo-
poietin degradation by platelets sequestered in the spleen has
also been demonstrated to contribute to thrombocytopenia
in cirrhotic patients.15
Whole blood assays such as thromboelastography, platelet
function tests, and thrombin generation assays are the best
available modalities today to interpret the hemostatic status of
patients with liver disease. These investigations can be used to
guide precise treatment of any coagulation cascade component
deficiency. Administration of prothrombin complex concen-
trates instead of fresh frozen plasma may assist in avoiding
fluid overload and potential portal hypertension exacerbation.
However, further research is required into the assessment and
treatment of liver disease associated hemostatic disorders.
Risk Models in Cirrhosis
Child and Turcotte of the University of Michigan first formu-
lated an empirical predictive model for patients with hepatic
Thoracic and Cardiovascular Surgeon Vol. 63 No. 1/2015
Dimarakis et al.
dysfunction undergoing portosystemic surgery.16 This incor-
porated serum albumin level, serum bilirubin level, ascites,
hepatic encephalopathy, and nutritional status classifying
patients in to class A, B, or C. Pugh updated this model
(Child–Turcotte–Pugh [CTP] score) by including prolongation
of the prothrombin time and omitting assessment of body
nutrition.17 To eliminate “subjective” parameters the Model
for End-Stage Liver Disease (MELD) score was developed by
physicians of the Mayo Clinic for patients undergoing trans-
jugular intrahepatic portosystemic shunting (TIPS).18 The
MELD score in its current form uses serum bilirubin level,
serum creatinine level, and international normalized ratio for
prothrombin time.19 It has subsequently been validated for
hepatic disease in many other settings. A more detailed
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description of the calculation of CTP and MELD scores is
provided in ►Table 1. Of note further “modified” scores
have been derived from the CTP and MELD scores.20,21
Mortality rates of 9 to 19% have been reported following
general surgical procedures.22–25 Mortality following elective
surgery has been found to be higher in patients with cirrhosis
even in the absence of portal hypertension.4 Increased mor-
tality following colorectal resections, emergency laparotomy,
and abdominal aortic aneurysm repair in patients with liver
disease has also been shown.26–28 Both MELD and CTP scores
have been found to be associated with adverse outcomes
following general surgery and are potentially useful for
preoperative risk assessment.22,25,28,29 Recent application
of the MELD score beyond cirrhosis has shown its potential
in predicting perioperative bleeding and mortality in left
ventricular assist device patients.30
Existing liver disease scoring systems are far from perfect
with many groups having demonstrated further parameters
of potentially useful prognostic value. Incorporation of serum
sodium concentration to the MELD score has been shown to
increase the prognostic value.31 In patients with refractory
Table 1 Scoring CTP and MELD criteria for end-stage chronic
liver disease
Clinical/biochemical Points scored
measurements
1 2 3
CTP classification
Encephalopathy None Grade 1–2 Grade 3–4
Ascites Absent Slight Moderate
Bilirubin (mg/dL) <2 2–3 >3
Albumin (g/dL) > 3.5 2.8–3.5 < 2.8
Prothrombin time 1–4 4–6 >6
(sec prolonged)
MELD
MELD ¼ 9.57  loge(creatinine mg/dL) þ 3.78  loge
(total bilirubin mg/dL) þ 11.2  loge (INR) þ 6.43a
Abbreviations: CTP, Child–Turcotte–Pugh; MELD, Model for End-stage
Liver Disease.
Notes: Scores 5 and 6 are designated as grade A, scores 7 to 9 are
designated as grade B, while 10 to 15 are designated as grade C.
Prognosis is related to grading. (Adapted from Pugh et al.17)
a
Adapted from Kamath and Kim.19
 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery Dimarakis et al. 61

ascites treated with TIPS survival seems to be linked with Table 2 A brief description of investigations that may be
bilirubin level below 50 μmol/L and a platelet count above necessary to be performed during the preoperative workup of
75  109/L.32 The prognostic value of a low platelet count has cirrhosis
been demonstrated for cardiac surgery patients.33 Research
into noninvasive serum markers of hepatic dysfunction to History
identify cirrhotic patients in which esophageal varices may Physical examination
prove clinically relevant is also being performed.34 Serum Blood tests
cholinesterase is another biomarker that has been evaluated
Liver function tests
in cirrhotic patients undergoing cardiac surgery.35,36 Further-
more, conventional laboratory measurement of prothrombin Gamma-glutamyl transferase
time may require specialized calibration for cirrhotic Albumin
patients.37 Electrolytes
Hematology/clotting studiesa
Perioperative Management of Cirrhosis

Hepatic tissue is characterized by the ability to regenerate
following injury as described in the myth of Prometheus.
With repeated injury though, this regenerative capacity
becomes limited and fibrous scarring described as cirrhosis
ensues. This has a knock-on-effect on protein synthesis,
excretion of bilirubin, coagulation, waste-product/drug clear-
ance, energy/hormonal metabolism, as well as immune re-
sponse. Hepatic tissue in cirrhosis is more susceptible to
ischemia that may in turn result in the release of a cascade
of inflammatory mediators.38 Preoperative assessment
should focus on synthetic function (best assessed by
MELD), optimization of specific complications (malnutrition,
ascites, encephalopathy, etc.), and correction of coagulopathy.
Interestingly, central venous pressure has been found to be a
valuable predictor of short-term outcome in patients with
cirrhosis undergoing cardiac surgery.39 A multidisciplinary
approach should be maintained involving cardiac anesthesi-
ology, hepatology, and hematology (►Table 2).
Poor tolerance of invasive stress, coagulopathy, and an
increased susceptibility to infection characterize patients
with cirrhosis. They are also at a much-increased risk of
developing postoperative liver failure with associated en-
cephalopathy, ascites, and jaundice. Impaired coagulation
increases the risk of bleeding both intraoperatively and
postoperatively. In addition, there is the possibility that
esophageal varices may be disturbed and rupture leading to
massive hemorrhage. The likelihood of bleeding will dictate
the safety of transesophageal echocardiography, for example.
Intraoperative anesthetic drug selection should be individu-
alized considering not only hepatic metabolism/elimination
but also the effect on hepatic blood flow to preserve hepatic
function. The risk of postoperative infection is also increased
in patients with liver cirrhosis because of altered immuno-
logical function caused by metabolic abnormalities and poor
nutritional status.
Avoiding cardiopulmonary bypass, nonpulsatile flow and
perioperative vasopressor support which have all been asso-
ciated with hepatic decompensation following cardiac sur-
gery are strategies that could potentially improve outcomes in
patients with liver disease.40 Although minimally invasive
approaches are advocated in cirrhotic patients surprisingly
mortality does not appear to be affected by off-pump sur-
gery.41,42 The beneficial use of continuous ultrafiltration
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Virology
Autoantibodies
Ceruloplasmin
Alpha-1 antitrypsin
Alpha-fetoprotein
Hepatic biopsy
Endoscopy
Imaging
Ultrasound with Doppler of the portal vessels
Computed tomography
Magnetic resonance imaging
Severity scoring
Cardiac investigationsb
Coronary angiography
Echocardiography
Right heart catheterization
Note: A multidisciplinary team approach should also involve hematologya
and cardiologyb before surgery.
during cardiopulmonary bypass for valvular surgery in cir-
rhotic patients has also been documented in a prospective,
randomized double-blinded placebo study.43
Cardiac Surgery in Patients with Cirrhosis
A growing body of research has clearly associated cirrhosis
with an increased mortality risk in cardiac surgery as seen
in ►Table 3.4,33,36,39,41,42,44–57 Most common causes of death
include sepsis, bowel ischemia, hepatic decompensation with
multisystem organ failure, postoperative myocardial infarc-
tion, and uncontrollable hemorrhage.
Suman et al performed a retrospective study of 44 patients
with cirrhosis who underwent cardiac surgery with cardio-
pulmonary bypass.47 A significant association between both
hepatic decompensation and mortality with CTP class/score
and MELD score was documented, concluding that patients
with a CTP score of < 7 could be operated on safely.
Morisaki et al reported morbidity and mortality outcomes
in 42 patients who underwent major cardiovascular proce-
dures to be 31 and 9.5%, respectively.33 MELD score (> 13) was

Thoracic and Cardiovascular Surgeon Vol. 63 No. 1/2015

62 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery Dimarakis et al.

Table 3 Clinical studies of adult cardiac surgery in patients with hepatic cirrhosis

Study Type of study Number Child–Turcotte– Operative mortality MELD score Operative mortality
of Pugh (%) (n) (%)
patients classification (n)
Klemperer Retrospective 13 A (8); B (5); C (0) A (0); B (80)
et al44
Bizouarn Prospective 12 A (10); B (2); C (0) A (0); B (50)
et al45
Hayashida Retrospective 18 A (10); B (7); C (1) A (0); B (28.6);
et al46 C (100)
Suman Retrospective 44 A (31); B (12); C (1) A (3.2); B (41.7); 6–27 18.3 þ 6.9
et al47 C (100) (overall range) (15.9)
Lin et al48 Retrospective 18 A (13); B (4); C (1) A (5.5); B (0); C (0)

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Filsoufi Retrospective 27 A (10); B (11); C (6) A (11); B (18); C (67) 14.2  4.2
et al49
An et al50 Retrospective 24 A (17); B (6); C (1) A (6); B (67); C (100)
Ailawadi Retrospective 37 < 10 (54); < 10 (1.9);
et al51 10–14.9 (44); 10–14.9 (6.8);
15–19.9 (11); 15–19.9 (27.3);
 20 (13)  20 (30.8)
Shaheen Retrospective 711 N/A N/A N/A 17.2 (overall)
et al41
Murashita Retrospective 12 A (6); B (6); C (0) A (50); B (17)
et al36
a
Csikesz Retrospective 1,575 N/A N/A N/A
et al4
Gundling Retrospective 47 A (33); B (14); C (0) A (6.1); B (50)
et al52
Morisaki Retrospective 42 A (30); B (12); C (0) A (0); B (33.3)
et al33
Thielmann Retrospective 57 A (39); B (14); C (4) A (15.4); B (50); 13.0  6 < 13.5 (9);
et al53 C (100) > 13.5 (56)
Marui Retrospective 99 N/A N/A N/A 5 (overall)
et al42
Sugimura Retrospective 13 A (7); B (5); C (1) A (0); B (20); C (0) 8.6  2.5
et al54 (6.4–14.1)
Vanhuyse Retrospective 34 A (22); B (10); C (2) A (18); B (40);  15 (7) < 15 (20);
et al55 C (100)  15 (44.4)
Macaron Retrospectiveb 54 < 8 (44),  8 (10) < 8 (4.7),  8 (55.6) 10 (median)
et al56 (6–26)
Arif Retrospective 109 A (74); B (29); C (6) A (18.9); B (41.4); 11.6  5.1 10.66  4.64
et al57 C (33.3) (mean) (survivor group)
14  5.71 (30-d
mortality group)
Lopez- Prospective 58 A (34); B (21); C (3) A (0); B (23.8); 16  5.4 15  4.57
Delgado C (66.6) (survivor group)
et al39 23  5.4
(nonsurvivor group)

Notes: The weighted average mortality rates were calculated from studies that reported mortality according to CTP class. Reported data regarding
MELD score and associated mortality are also provided. For registry articles, only overall mortality is reported.
a
Cirrhotic patients had an 8-fold increase risk of death (hazard ratio [HR], 8.0; 95% confidence interval [CI], 5.0–13.0); if portal hypertension was
present patients had a 22.7-fold increase in risk of death (HR, 22.7; 95% CI, 10.0–53.8).
b
Propensity score matching with 216 controls.

Thoracic and Cardiovascular Surgeon Vol. 63 No. 1/2015

 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery
identified as a reliable predictor in addition to low platelet
count (< 9.6  104/μL). In an attempt to compare the various
available to date risk prediction models for cirrhotic pati-
ents undergoing cardiac surgery, Thielmann et al recently
published data from 57 patients.53 It was clearly shown that
mortality progressively increased with severity of hepatic
dysfunction. Gundling et al compared data from 47 cirrhotic
patients who underwent cardiac surgery with a propensity-
score pair-matched control group.52 Analysis demonstrated
that operative risk for Child–Pugh class A status was not
significantly raised compared with controls. Child–Pugh class
B status was linked to a 15.5-fold increase in risk compared
with class A patients. Marui et al reported data from a
Japanese multicenter registry regarding 99 patients who
underwent coronary revascularization with conventional
(n ¼ 58) and off-pump (n ¼ 41) approaches.42 Freedom
from all-cause death at 30 days, 1 year, and 3 years was
96.0, 92.9, and 80.1%, respectively.
Most recently, Arif et al reported a large retrospective
series of 109 cirrhotic patients undergoing cardiac surgery.
Reported 30-day mortality was 26% with 5-year survival
being 19%.57 In-hospital mortality for class A patients was
approximately 20.5% with in-hospital mortality for classes B
and C being more than double this figure.
Combining the results of previous studies of cardiac
surgery in patients with hepatic disease that have strati-
fied mortality results by CTP classification demonstrates a
weighted mean mortality of 9.88% (standard deviation [SD]
9.69) for patients in CTP class A, 38.61% (SD 16.13) for
patients in CTP class B, and 69.23% (SD 28.55) in patients
with CTP class C.
Discussion
Advances in surgical techniques and intensive care manage-
ment have translated into declining cardiac surgery mortality
rates over recent years despite an increase in patient risk
profile.1,2 As cirrhosis is linked with increased rates of
morbidity and mortality following surgery, the need for
risk stratification is clear, particularly in an era where cardiac
surgical outcomes are heavily scrutinized. However, both the
Society of Thoracic Surgeons risk model for coronary artery
bypass grafting (CABG) surgery and the European System for
Cardiac Operative Risk Evaluation II (EuroSCORE II) risk model
do not include hepatic dysfunction as a risk factor, meaning
cardiac surgical risk is most likely to be underestimated in
these patients.58,59 Available data providing insight regarding
performance of risk stratification models in this subset of
patients is restricted to small institutional studies and sub-
analyses of registry data.
In a retrospective, observational single-center study in-
vestigators compared the MELD score, the CTP classification,
and the European System for Cardiac Operative Risk Evalua-
tion (EuroSCORE) for risk prediction in 57 cirrhotic patients.53
The MELD score demonstrated superior prediction for in-
hospital mortality and long-term survival with the best cutoff
value for MELD score at 13.5. Although CTP class was found
inferior to MELD score, it was clearly seen that hospital and
Dimarakis et al. 63
long-term outcome was significantly better in patients with
CTP class A as compared with classes B and C. In addition,
patient outcome in CTP class C was significantly worse
compared with classes A and B.
In another analysis of outcomes of 109 patients with
cirrhosis, Arif et al demonstrated a significantly better dis-
crimination for the MELD and logistic EuroSCORE compared
with the Child classification.57 The authors calculated the
ideal cutoff point for predicting 30-day mortality for the
MELD score at 9.5 points and for EuroSCORE at 14.8% but
acknowledged the low sensitivity and specificity of these
cutoff values. Lopez-Delgado et al also reported the MELD
score being the most effective predictor for short-term out-
come; they further reported an optimal cutoff level for the
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MELD score of 18.5, with a sensitivity of 85.7% and a specific-
ity of 83.7%.39 In the only available propensity score matching
analysis including 54 patients with cirrhosis, it was reported
that a CTP score less than 8 does not confer significant
increases in postoperative mortality and morbidity.56
Data from 772 patients with cirrhosis who underwent
major digestive, orthopedic, or cardiovascular surgery dem-
onstrated good discrimination of the MELD score with 30-day
mortality rates of 6% and > 50% for MELD scores of < 8
and > 20, respectively.29 Shaheen et al clearly demonstrated
an increase in CABG surgery procedures among patients with
cirrhosis.41 The authors attribute this trend to an increase in
coronary artery disease rates among cirrhotic patients with
lowering of the associated threshold for surgical referral in
addition to a rising prevalence of cirrhosis. Data were retro-
spectively reviewed from 711 patients with cirrhosis that
underwent CABG. It was reported that patients with cirrhosis
had an increased risk of mortality (17 vs. 3%), complications
(43 vs. 28%), and greater length of stay and hospital costs
(p < 0.0001). Predictors of mortality in this cohort included
age older than 60 years, female gender, ascites, and conges-
tive heart failure. Unfortunately, correlation with the CTP was
not performed as necessary laboratory data were not avail-
able, although it is suggested that vast majority of patients
had class A cirrhosis.41
In another registry study reliant on diagnostic co-
ding, patients with cirrhosis undergoing CABG surgery
(n ¼ 1,575) were shown to be at the greatest risk for death
among four index operations (cholecystectomy, colectomy,
abdominal aortic aneurysm repair, and CABG surgery).4 Cir-
rhosis increased risk of death by 8-fold, while cirrhosis com-
plicated with portal hypertension increased risk of death by
22.7-fold. In addition, cirrhotic patients were found to incur
significantly higher total charges and longer lengths of stay
when compared with noncirrhotic patients across the board.
Understanding the pathophysiology of the natural course
of cirrhosis remains an important aspect of perioperative
patient management.60 Associated comorbidities should al-
ways be considered especially in the context of assessing
renal dysfunction as the latter may not be solely attributed to
the underlying cirrhosis.61 The impact of coagulopathy on
outcomes becomes apparent from the fact that scoring sys-
tems assessing severity of chronic hepatic disease encompass
parameters of coagulation. As discussed earlier, the use of
Thoracic and Cardiovascular Surgeon Vol. 63 No. 1/2015
64 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery
isolated routine laboratory tests such as prothrombin time or
platelet count do not reflect the actual hemostatic status and
may therefore be misleading.
The fate of cirrhotic patients being admitted to intensive
care unit has been studied extensively with the presence
of  3 failing organ systems being associated with 90% mor-
tality.62 Anesthesia and surgery have been associated with
increased rates of morbidity in cirrhosis.38 Studies included
in ►Table 2 have identified the commonest causes of mor-
bidity as respiratory failure, renal failure requiring dialysis,
ischemic or hemorrhagic gastrointestinal complications, sep-
sis, deep sternal infection, superficial wound infection, he-
patic decompensation, reoperation for bleeding, and cardiac
events. Class A patients develop less complications when
compared with class B and C.44,48,50,55 It is crucial that
postoperative intensive care management focuses on fluid
management, early diagnosis of infection, and prevention of
hepatic decompensation.
At present, both CTP and MELD scores seem complemen-
tary rather than competitive in predicting early outcomes.63
Both may assist in identifying cirrhotic patients at high risk
for cardiac surgery. Preoperative medical risk assessment and
optimization along with evidence-based management strat-
egies may optimize postsurgical outcomes.
It appears from available clinical studies that cirrhotic
patients are at increased risk of mortality following cardiac
surgery with considerable morbidity. In more detail, patients
in class A exhibit mortality rates of nearly 10%, while patients
in class C have a dismal prognosis and therefore less invasive
treatment options must be considered. Patients with class B
liver disease are the cohort most likely to benefit from identi-
fying favorable surgical candidates. It is apparent that class B is
a heterogeneous condition including patients with frankly
different prognosis, and clinicians focus should be to identify
which item of the CTP classification gauges the score.64 In this
group, the high risk of postoperative morbidity, increased
length of stay, and total cost require a complex multidisciplin-
ary infrastructure to secure patient progress to discharge.4,41
The multidisciplinary approach involving liver medicine
and transplantation services, hematology, and cardiac sur-
gery intensive care remains key. To this effect, Telem et al have
demonstrated lower than anticipated mortality rate for gen-
eral surgery in advanced cirrhosis.65 They further suggest that
regionalization of care for cirrhotic patients with advanced
disease might improve outcomes.
This review provides cardiac surgeons and patients with
additional information for meaningful preoperative decision
making and providing informed consent, respectively, for this
subgroup of patients. The importance of a multidisciplin-
ary approach on an individual patient basis cannot be
overemphasized.
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66 Impact of Hepatic Cirrhosis on Outcome in Adult Cardiac Surgery Dimarakis et al.

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