Cardiac Surgery Management in Patients With Liver Cirrhosis

Liver cirrhosis substantially increases perioperative morbidity and mortality in patients undergoing cardiac surgery through coagulopathy, portal hypertension, cirrhotic cardiomyopathy, renal dysfunction, and immune dysregulation. Conventional cardiac risk scores underestimate this risk because these metrics do not incorporate variables related to hepatic function, highlighting the need to integrate the Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores. Novel predictive models, such as the Veterans Outcomes and Costs Associated with Liver Disease - Penn (VOCAL-Penn) and Mayo Postoperative Mortality Risk Score (Mayo scores), demonstrate superior discriminatory performance by incorporating surgery-specific variables. This narrative review synthesizes the evidence on risk stratification, preoperative optimization, intraoperative management, and postoperative care in patients with liver cirrhosis undergoing cardiac surgery. A structured, multidisciplinary approach that incorporates systematic hepatic assessment, careful patient selection using integrated cardiac-hepatic risk models, tailored intraoperative techniques to minimize cardiopulmonary bypass (CPB)-related injury, and vigilant postoperative organ support can improve outcomes in this high-risk population. This review provides practical, phase-oriented recommendations with evidence grading, critical discussion of controversies, and acknowledgment of the limitations inherent in the available literature.