肝硬化患者心脏手术的早期和晚期结果：8 年中 47 例患者的生存率回顾性分析。
Early and late outcomes of cardiac operations in patients with cirrhosis: a retrospective survival-rate analysis of 47 patients over 8 years.
机构信息
Department of Gastroenterology, Bogenhausen Academic Teaching Hospital dInstitut für medizinische Statistik und Epidemiologie, Technical University of Munich, University of Munich, Munich, Germany.
出版信息
Eur J Gastroenterol Hepatol. 2010 Dec;22(12):1466-73. doi: 10.1097/MEG.0b013e32834059b6.
OBJECTIVES
Patients with liver cirrhosis are considered as high-risk population for cardiac surgery. The aim of this study was to review mortality and mid-term outcome of patients with liver cirrhosis requiring coronary artery bypass graft (CABG), valve replacement, or combined procedures.
METHODS
Between July 1997 and December 2006, 47 patients (mean age 65.4 ± 11.7 years) with liver cirrhosis were operated for CABG (21 patients), aortic valve replacement /mitral valve replacement (14 patients), CABG/VR (9 patients) or aortic dissection/tumorexstirpation (3 patients) (group I). Thirty-three patients were classified as Child-Pugh class A (subgroup A), 14 patients as Child-Pugh class B cirrhosis (subgroup B). Postoperative complications/mortality were analyzed retrospectively and compared with a propensity-score pair-matched control group of 47 patients (group II). Follow-up ranged from 0.1 to 11.5 years (mean 3.9 ± 0.25 years) and was complete for 100%.
RESULTS
Necessity of blood products was higher in group I (red cells, fresh frozen plama, platelets; P < 0.01). Chest-tube output (group I 1113 ± 857 vs. group II 849 ± 521; P = 0.15) and re-exploration rate (8.5 vs. 0%; P = 0.11) were slightly accelerated. Ventilation time and ICU-stay was prolonged (P < 0.015). Thirty-day mortality showed 19.1% (group I) versus 8.5% (group II) (P < 0.01), 6.1% (subgroup A) versus 50% (subgroup B) (P < 0.01). Operative risk in subgroup A was not significantly increased compared with control group (P = 0.68). In Child-B operative risk was 15.5-fold higher than in Child-A cirrhosis (P < 0.001). Postcardiotomy syndrome and pleurisy were more frequent in the cirrhosis group (4/47 vs. 0/47; P = 0.11). Actuarial survival after 3, 5 and 8 years was: group I 78.6, 75.6, and 70.2% versus group II 89.1, 85.7, and 85.7% (P = 0.08). Subgroup survival analysis was: group A 90.7, 86.6, and 78.5% versus group B 50, 50, and 50% (P < 0.01).
CONCLUSION
Cardiac surgery can be performed safely in patients with Child-Pugh class A and selected patients with Child-Pugh class B cirrhosis. Mid-term survival-rates within 8 years were not significantly different compared with a propensity-score pair-matched control group without cirrhosis.
目的
患有肝硬化的患者被认为是心脏手术的高危人群。本研究的目的是回顾需要冠状动脉旁路移植术（CABG）、瓣膜置换术或联合手术的肝硬化患者的死亡率和中期结果。
方法
1997 年 7 月至 2006 年 12 月，47 例（平均年龄 65.4±11.7 岁）肝硬化患者接受 CABG（21 例）、主动脉瓣置换/二尖瓣置换（14 例）、CABG/VR（9 例）或主动脉夹层/肿瘤切除（3 例）（I 组）。33 例患者被归类为 Child-Pugh 分级 A（亚组 A），14 例患者被归类为 Child-Pugh 分级 B 肝硬化（亚组 B）。回顾性分析术后并发症/死亡率，并与 47 例（II 组）匹配倾向性评分的配对对照组进行比较。随访时间为 0.1 至 11.5 年（平均 3.9±0.25 年），随访率为 100%。
结果
I 组患者对血液制品的需求更高（红细胞、新鲜冷冻血浆、血小板；P<0.01）。胸部引流量（I 组 1113±857 与 II 组 849±521；P=0.15）和再次探查率（8.5%与 0%；P=0.11）略高。通气时间和 ICU 停留时间延长（P<0.015）。30 天死亡率为 19.1%（I 组）与 8.5%（II 组）（P<0.01），6.1%（亚组 A）与 50%（亚组 B）（P<0.01）。亚组 A 的手术风险与对照组相比无显著增加（P=0.68）。Child-B 手术风险是 Child-A 肝硬化的 15.5 倍（P<0.001）。手术后综合征和胸膜炎在肝硬化组更常见（4/47 与 0/47；P=0.11）。3、5 和 8 年后的累积生存率为：I 组 78.6%、75.6%和 70.2%，II 组 89.1%、85.7%和 85.7%（P=0.08）。亚组生存分析为：A 组 90.7%、86.6%和 78.5%，B 组 50%、50%和 50%（P<0.01）。
结论
Child-Pugh 分级 A 的患者和部分 Child-Pugh 分级 B 肝硬化患者可以安全地进行心脏手术。8 年内的中期生存率与无肝硬化的倾向性评分配对对照组无显著差异。
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