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[Perioperative management in patients with liver cirrhosis undergoing open heart surgery]
1Department of Thoracic Cardiovascular Surgery, Mimihara General Hospital, Sakai, Japan.
Insights
Managing liver cirrhosis patients undergoing open heart surgery requires careful attention to prevent complications. Key strategies include minimizing blood loss and preserving liver function to improve outcomes.
Area of Science:
- Cardiology
- Hepatology
- Cardiothoracic Surgery
Context:
- Open heart surgery in patients with liver cirrhosis presents significant perioperative challenges.
- Severe tricuspid regurgitation and prior cardiac surgeries (redo operations) increase surgical complexity.
- Preoperative indicators like elevated bilirubin, impaired indocyanine green retention test (ICGR15), and low platelet counts suggest high surgical risk.
Purpose:
- To evaluate the perioperative management strategies for patients with liver cirrhosis undergoing open heart surgery.
- To identify factors influencing postoperative outcomes in this high-risk patient population.
Summary:
- Four patients with liver cirrhosis (NYHA class III, severe tricuspid regurgitation) underwent open heart surgery, with three having previous operations.
- Two patients with uncomplicated courses maintained good cardiac function without blood transfusion.
- Two patients undergoing re-redo operations experienced massive hemorrhage, requiring transfusions and leading to severe complications (respiratory failure, multiple organ failure).
- Survivors improved to NYHA class I.
- Effective perioperative management necessitates avoiding hemorrhage, maintaining hepatic blood flow, resolving congestion, and preventing complications like bleeding, infection, and renal failure.
- Sufficient hemostasis and autologous platelet-rich plasma were crucial in preventing massive hemorrhage.
Impact:
- Highlights the critical need for comprehensive management strategies in liver cirrhosis patients undergoing cardiac surgery.
- Emphasizes the importance of meticulous surgical hemostasis and blood management, including autologous platelet-rich plasma, to mitigate hemorrhage risk.
- Suggests that successful management can lead to improved cardiac functional class post-surgery.
Abstract:
Perioperative management of patients with liver cirrhosis undergoing open heart surgery (3 males and 1 female, mean age 57.3 years) was evaluated. All 4 patients had NYHA class III acquired valvular heart disease accompanied by severe tricuspid regurgitation, and the operation was a redo operation in 3 of them. Preoperatively, the total serum bilirubin was 1.7 mg/dl, ICGR15 24.3 +/- 1.7%, and blood platelet count was 83,000 +/- 19,000/m3. The postoperative course was uneventful in 2 patients who maintained good cardiac function and did not require homologous blood transfusion. The other two patients who underwent a re-redo operation, sustained a large volume of hemorrhage, and required massive transfusion showed severe postoperative complications (respiratory failure in 1, multiple organ failure in 1). The stage of the disease improved to NYHA class I in all 3 patients who survived the operation. Comprehensive measures including avoidance of massive hemorrhage, preservation of the hepatic blood flow, resolution of hepatic congestion, and prevention of complications such as digestive tract bleeding, infections, and renal failure are considered to be needed for prevention of postoperative liver failure. Especially, sufficient surgical hemostasis and autologous platelet rich plasma were useful for prevention of massive hemorrhage.