Liver cirrhosis: Still an elusive risk factor in the current EuroSCORE system

Liver cirrhosis increases the risk of death in patients having cardiac surgery, and the risk is markedly dependent on the actual stage. The EuroSCORE II, however, does not specifically address the risk of death of patients with liver cirrhosis. We investigated the predictive power of EuroSCORE II in patients with liver cirrhosis.

Between 2000 and 2020, a total of 218 patients with liver cirrhosis underwent cardiac surgery. To improve the predictive value of the EuroSCORE II, we calculated additional β-coefficients to include liver cirrhosis in the EuroSCORE IIb. The control group included 5,764 patients without liver cirrhosis from the same period.

Of the 5,764 patients without cirrhosis, 8.9% died early. Of those with cirrhosis, 8.9% of 146 patients with Child A stage, 52.9% of 51 patients with Child B stage and 100% of 21 patients with Child C stage died. Moreover, the EuroSCORE II showed a poor predictive value for patients in Child B and C stages. The resulting values of calculated β using the area under the curve of the receiver operating characteristic and bootstrapping for Child stages as predictors of mortality were as follows: βA = 0.1640205, βB= 2.9911625 and βC= 6.2501248. By calculating the updated EuroSCORE IIb and regenerating the receiver operating characteristic curves, we were able to demonstrate an improvement in area under the curve values. Postoperative complications, need for extracorporeal membrane oxygenation or intra-aortic balloon pump implants, intensive care unit stays and hospital stays were significantly higher in cirrhotic patients with cirrhosis compared with patients without cirrhosis. The most common cause of liver cirrhosis was alcohol abuse (55.5%).

Although patients with liver cirrhosis represent only a small proportion of cardiac surgical cases, the poor outcomes are particularly relevant in patients with advanced stages of the disease. Our study results show that Child class A patients show outcomes similar to those of patients without liver disease whereas Child class C patients appear to be nearly inoperable, i.e. can only be operated on with exceptional risks. Including these patients in the EuroSCORE II calculation would thus represent an improvement in preoperative mortality risk assessment.