肝硬化患者心脏手术（CASTER）研究：早期和长期结果。

Cardiac Surgery in Patients With Liver Cirrhosis (CASTER) Study: Early and Long-Term Outcomes.

机构信息

Cardiac Surgery Division, IRCCS Policlinico San Donato, San Donato Milanese, Italy.

出版信息

Ann Thorac Surg. 2021 Apr;111(4):1242-1251. doi: 10.1016/j.athoracsur.2020.06.110. Epub 2020 Sep 11.

DOI:10.1016/j.athoracsur.2020.06.110

PMID:32919974

Abstract

BACKGROUND

Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.

METHODS

All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes.

RESULTS

The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score <12), or advanced CTP class B (MELD score >12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P = .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P = .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P = .238).

CONCLUSIONS

CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.

摘要

背景

接受心脏手术（CS）的肝硬化（LC）患者围手术期死亡率和发病率较高，但针对这一主题的广泛研究却很少。

方法

本回顾性队列研究纳入了 2000 年至 2017 年期间在意大利 10 家机构接受 CS 治疗的所有成年 LC 患者。根据术前的 Child-Turcotte-Pugh（CTP）评分和终末期肝病模型（MELD）评分对 LC 进行分类。对总体人群和 CTP 分类人群进行早期和中期预后分析。

结果

该研究人群包括 144 例患者（平均年龄 66±9 岁，69%为男性）。98 例、20 例和 26 例患者分别为 CTP 分级 A、早期 CTP 分级 B（MELD 评分<12）和晚期 CTP 分级 B（MELD 评分>12）。主要的 LC 病因是病毒性（43%）和酒精性（36%）。肝脏相关临床表现（腹水、食管静脉曲张和脑病）和实验室值（估算肾小球滤过率、血清白蛋白和胆红素、血小板计数）在 CTP 分级中显著恶化（P=0.001）。36%的患者行冠状动脉旁路移植术或瓣膜手术（87%为生物瓣），50%的患者行瓣膜手术。在晚期 CTP 分级 B 中，术后并发症（尤其是急性肾损伤、肝脏并发症和住院时间）显著恶化（P=0.001）。值得注意的是，在总体人群和亚组中，观察到的死亡率是 EuroSCORE（欧洲心脏手术风险评估系统）II 预测死亡率的 3 倍或 4 倍。在 Kaplan-Meier 分析中，总体人群的 1 年和 5 年累积生存率分别为 82%±3%和 77%±4%。CTP 分级 A、早期 CTP 分级 B 和晚期 CTP 分级 B 的 5 年生存率分别为 72%±5%、68%±11%和 61%±10%（P=0.238）。