Harrington Phillips B, McAlexander William W, Bryant Ayesha S, Wallace Payden, Massey Julia, Gray Stephen, Kukreja Manish, Cleveland David C, Kirklin James K, Davies James E
Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
Division of Cardiothoracic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
Ann Thorac Surg. 2017 Feb;103(2):541-545. doi: 10.1016/j.athoracsur.2016.06.023. Epub 2016 Sep 9.
There is a paucity of information available regarding the impact of cardiac surgical procedures on patients who have undergone previous liver transplantation. The primary purpose of this study was to ascertain the survival rate and predictors of death in this specific patient population.
This retrospective cohort study consisted of a consecutive series of patients with a functioning liver allograft who subsequently underwent cardiac surgical procedures between January 1991 and December 2012. The optimal Model for End-Stage Liver Disease (MELD) score for predicting late death was identified using receiver operating characteristic curve analysis. Risk of postoperative death was determined by parametric hazard analysis.
Between January 1991 and December 2012, 43 patients (median age, 60 years) underwent cardiac surgical procedures after liver transplantation. The median interval between liver transplant and cardiac operation was 63 months (range, 1.1 to 217 months). Three operative deaths and 24 late deaths occurred. Receiver operating characteristic curve analysis identified the optimal preoperative and postoperative MELD score cut points for predicting late death as greater than 13.8 (area under the curve = 0.674) and greater than 17 (area under the curve = 0.633), respectively. Patients with a preoperative MELD score of 13.8 or less had significantly greater survival rates than those with a MELD score greater than 13.8 (p = 0.028); patients with a postoperative MELD score of 17 of less had significantly greater survival rates than those with a MELD score greater than 17 (p < 0.001). Multivariate parametric hazard analysis identified postoperative peak creatinine level as a statistically significant predictor of death (relative risk, 1.8; p = 0.01). The 1-, 5-, and 10-year Kaplan-Meier survival rates were 90%, 51%, and 35%, respectively; postoperative mortality rates followed a constant phase model with a hazard of death of 10% per year.
Cardiac surgical procedures can be performed with acceptable short-term and long-term outcomes in liver transplant recipients. Elevated preoperative and postoperative MELD scores and postoperative peak creatinine level may portend death in this cohort. There is a constant hazard of death of 10% per year.
关于心脏外科手术对既往接受过肝移植患者的影响，现有信息匮乏。本研究的主要目的是确定这一特定患者群体的生存率及死亡预测因素。
这项回顾性队列研究纳入了1991年1月至2012年12月期间连续一系列接受肝移植且移植肝功能良好、随后接受心脏外科手术的患者。使用受试者工作特征曲线分析确定预测晚期死亡的最佳终末期肝病模型（MELD）评分。通过参数化风险分析确定术后死亡风险。
1991年1月至2012年12月期间，43例患者（中位年龄60岁）在肝移植后接受了心脏外科手术。肝移植与心脏手术之间的中位间隔时间为63个月（范围1.1至217个月）。发生了3例手术死亡和24例晚期死亡。受试者工作特征曲线分析确定预测晚期死亡的术前和术后MELD评分最佳切点分别为大于13.8（曲线下面积 = 0.674）和大于17（曲线下面积 = 0.633）。术前MELD评分为13.8或更低的患者生存率显著高于MELD评分大于13.8的患者（p = 0.028）；术后MELD评分为17或更低的患者生存率显著高于MELD评分大于17的患者（p < 0.001）。多变量参数化风险分析确定术后肌酐峰值水平是死亡的统计学显著预测因素（相对风险，1.8；p = 0.01）。1年、5年和10年的Kaplan-Meier生存率分别为90%、51%和35%；术后死亡率遵循恒定阶段模型，每年死亡风险为10%。
肝移植受者进行心脏外科手术可获得可接受的短期和长期结果。术前和术后MELD评分升高以及术后肌酐峰值水平可能预示该队列患者死亡。每年有10%的恒定死亡风险。
