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CABG in patients with liver cirrhosis: to pump or not to pump?
Stephanie M Jiang1, Kiera Liblik2, Adrian Baranchuk2
1Division of Cardiac Surgery, Queen's University, Kingston, ON, Canada.
Insights
Coronary artery bypass grafting in cirrhotic patients carries high risk. Current evidence does not support that avoiding cardiopulmonary bypass (CPB) offers benefits over its use in on-pump (ONCABG) versus off-pump (OPCAB) procedures.
Area of Science:
- Cardiovascular Surgery
- Hepatology
- Critical Care Medicine
Background:
- Coronary artery bypass grafting (CABG) in patients with liver cirrhosis is associated with significant morbidity and mortality.
- The utility of cardiopulmonary bypass (CPB) in this high-risk population remains debated.
- Existing literature comparing on-pump (ONCABG) and off-pump (OPCAB) techniques in cirrhotic patients is limited.
Purpose of the Study:
- To review and compare the outcomes of ONCABG and OPCAB in patients with liver cirrhosis.
- To evaluate the impact of CPB avoidance on morbidity and mortality in this cohort.
- To identify the current evidence regarding surgical revascularization techniques in cirrhotic patients.
Main Methods:
- A comprehensive literature search was performed in PubMed/MEDLINE and EMBASE databases up to January 2021.
- Included studies compared ONCABG and OPCAB outcomes in cirrhotic patients without concomitant procedures.
- Data extraction and analysis focused on perioperative morbidity and mortality rates.
Main Results:
- Two case studies and six retrospective cohort studies were identified.
- The largest population-based study suggested a survival benefit for OPCAB, but lacked liver disease severity data.
- The remaining studies found no significant difference in outcomes between ONCABG and OPCAB.
Conclusions:
- Surgical myocardial revascularization poses a high perioperative risk for patients with liver cirrhosis, regardless of the technique used.
- There is insufficient evidence to conclude that avoiding CPB is advantageous in this patient group.
- Further high-quality research is needed to guide surgical decisions in cirrhotic patients undergoing CABG.
Introduction:
Coronary artery bypass grafting in patients with established liver cirrhosis is generally associated with poor outcomes. Avoiding cardiopulmonary bypass (CPB) in these patients has not demonstrated any advantage over the use of CPB. We review the current available literature that compared the outcome of both on-pump (ONCABG) and off-pump (OPCAB) techniques in cirrhotic patients in terms of morbidity and mortality.
Areas Covered:
A comprehensive search was conducted in the PubMed/MEDLINE and EMBASE databases in January 2021. Articles that reported outcomes of OPCAB and/or ONCABG in cirrhotic patients with no concomitant surgical procedures were included. 829 unique abstracts were retrieved with title and abstract screening completed independently by two reviewers. Two case studies and six retrospective cohort studies were included. The largest study comprised more than 98% of the total population, showing some survival benefit for OPCAB over ONCABG. However, it was population-based and did not report the severity of liver. The remaining studies reported no clear difference in outcome between the two techniques.
Expert Opinion:
Surgical myocardial revascularisation carries high perioperative risk in patients with liver cirrhosis irrespective of the surgical technique. There is a lack of evidence to suggest that avoiding CPB in these patients may be beneficial.
