Original articles
Predicting outcome after cardiac surgery in patients with cirrhosis: A comparison of Child-Pugh and MELD scores

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Abstract

Background & Aims: This study aims to quantify the risk of cardiac surgery in patients with cirrhosis. Methods: Records of all adult patients with cirrhosis undergoing cardiac surgery using cardiopulmonary bypass at the Cleveland Clinic (Cleveland, OH) from January 1992 to June 2002 were analyzed for any relationship of Child-Pugh class and/or score and Model for End-Stage Liver Disease (MELD) score with outcome measures of hepatic decompensation and death during the first 3 months after surgery. Results: Forty-four patients underwent coronary artery bypass grafting (16 patients), valve surgery (16 patients), a combination of the 2 procedures (10 patients), or pericardiectomy (2 patients). Twelve patients (27%) developed hepatic decompensation, and 7 patients (16%) died. Proportions of hepatic decompensation were 3 of 31, 8 of 12, and 1 of 1 patients, and death, 1 of 31, 5 of 12, and 1 of 1 patients in Child-Pugh classes A, B, and C, respectively. The association of hepatic decompensation and mortality with Child-Pugh class, Child-Pugh score, and MELD score was significant (P < 0.005). Areas under the receiver operating characteristic curves for mortality were similar for Child-Pugh (0.84 ± 0.09) and MELD scores (0.87 ± 0.09). A cutoff Child-Pugh score >7 was found to have a sensitivity and specificity of 86% and 92% for mortality, with a negative predictive value of 97% (95% confidence interval [CI], 83–99) and positive predictive value of 67% (95% CI, 31–91), respectively. However, a similar cutoff value for MELD score could not be established. Conclusions: Child-Pugh score and/or class and MELD score are significantly associated with hepatic decompensation and mortality after cardiac surgery using cardiopulmonary bypass in patients with cirrhosis. Such surgery can be conducted safely in patients with a Child-Pugh score ≤7. Patients with a Child-Pugh score ≥8 have a significant risk for mortality.

Section snippets

Methods

The study was performed retrospectively with the approval of the institutional review board. Using computer coding, patients with cirrhosis who underwent cardiac surgery using CPB from January 1992 to June 2002 were identified. Their charts and computer records were studied. A diagnosis of cirrhosis was established from liver biopsy records or a combination of clinical findings and radiological imaging of the liver, including ultrasound, computed tomographic scan, or magnetic resonance imaging,

Statistical analysis

The outcome measures of hepatic decompensation and death were compared with a variety of explanatory variables, including age, sex, cause of cirrhosis, type of cardiac surgery, CP score and/or class, MELD score, bilirubin level, albumin level, international normalization ratio (INR), creatinine level, intubation time, CPB time, and anesthetic medications administered. Relationships between explanatory variables and outcome measures of hepatic decompensation and mortality were assessed by using

Results

Initially, 66 patients with possible cirrhosis undergoing cardiac surgery using CPB were identified. Twenty-two patients were excluded; 13 patients because the diagnosis of cirrhosis was not proven, and 9 patients because of unavailability of sufficient laboratory data. Forty-four patients with cirrhosis undergoing cardiac surgery using CPB were analyzed. Twenty-seven patients (61%) were men. Ages ranged from 15 to 74 years. Causes of cirrhosis were alcohol in 11 patients; hepatitis C,

Discussion

Our report on the outcome of cardiac surgery in patients with cirrhosis is the largest series published to date. Patients with well-compensated cirrhosis may safely undergo cardiac surgery using CPB. Our data show a similar and significant association of CP score and MELD score with hepatic decompensation and mortality. The best cutoff values of these scores for predicting mortality and hepatic decompensation were >7 for CP score and >13 for MELD score (Figure 3). Although both these cutoff

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