Modi Amit, Vohra Hunaid A, Barlow Clifford W
Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, UK.
Interact Cardiovasc Thorac Surg. 2010 Nov;11(5):630-4. doi: 10.1510/icvts.2010.241190. Epub 2010 Aug 25.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with liver cirrhosis have acceptable outcomes after undergoing cardiac surgery. Altogether 97 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. One prospective and another eight retrospective studies involving adult population of patients with liver cirrhosis undergoing various cardiac surgical procedures were selected. In these studies, the overall mortality was 17.1% and combined mean mortality for Child-Pugh class A, B and C was 5.2%, 35.4% and 70%, respectively. The major morbidity ranged from 20 to 60% in group A and 50 to 100% in the patients with more advanced hepatic disease. Some studies have demonstrated that thrombocytopenia, decreased serum cholinesterase and high preoperative total bilirubin levels are significantly associated with worse clinical outcomes. These studies, although with small samples, collectively demonstrate that patients with Child-Pugh class A cirrhosis tolerated cardiac surgical procedures with a mild increase in mortality and morbidity. However, the risk of mortality in patients with Child-Pugh class B and C or MELD score>13 is extremely high. Nevertheless, even if these patients underwent successful surgery, their long-term survival was significantly poorer and their health status remains compromised even well after cardiac surgery because of persistent liver dysfunction.
一篇心脏外科的最佳证据主题文章是按照结构化方案撰写的。所探讨的问题是肝硬化患者接受心脏手术后是否能获得可接受的预后。通过报告的检索共找到97篇论文，其中9篇提供了回答该临床问题的最佳证据。将作者、年份、期刊、研究国家、研究类型、所研究的患者群体、相关结局、结果及研究不足制成表格。选取了一项前瞻性研究和另外八项回顾性研究，这些研究涉及接受各种心脏外科手术的成年肝硬化患者群体。在这些研究中，总体死亡率为17.1%，Child-Pugh A级、B级和C级患者的合并平均死亡率分别为5.2%、35.4%和70%。A组的主要发病率在20%至60%之间，而肝病更严重的患者组发病率在50%至100%之间。一些研究表明，血小板减少、血清胆碱酯酶降低和术前总胆红素水平升高与较差的临床结局显著相关。这些研究虽然样本量较小，但共同表明Child-Pugh A级肝硬化患者能够耐受心脏外科手术，死亡率和发病率略有增加。然而，Child-Pugh B级和C级或终末期肝病模型（MELD）评分>13的患者死亡风险极高。尽管如此，即使这些患者手术成功，他们的长期生存率也显著较差，并且由于持续的肝功能障碍即使在心脏手术后很长时间健康状况仍受到损害。
