Valvular Heart Disease
Impact of Cirrhosis in Patients Who Underwent Surgical Aortic Valve Replacement

https://doi.org/10.1016/j.amjcard.2017.05.034Get rights and content

Cirrhosis is known to adversely affect cardiac surgery outcomes. Our objective was to quantify the morbidity, mortality, and cost that cirrhosis adds to surgical aortic valve replacement. From 1998 to 2011, 423,789 patients in the Nationwide Inpatient Sample Healthcare Cost Utilization Project underwent isolated aortic valve replacement; 2,769 (0.7%) had cirrhosis. Multivariable linear regression and 1:1 propensity matching were used to determine the effect of cirrhosis on postsurgical outcomes. The number of patients with cirrhosis who underwent surgical aortic valve replacement per year more than tripled during the 13-year study period. Patients with cirrhosis were more likely to be younger (p <0.0001), insured by Medicaid (p <0.0001), and operated on at an academic or high-volume hospital (p <0.05). Risk-adjusted mortality for patients with cirrhosis was 16%, compared with 5% for patients without cirrhosis. Risk factors for death included congestive heart failure, fluid and electrolyte imbalances, pulmonary circulation disorders, and weight loss. Among propensity-matched pairs, patients with cirrhosis had a higher mortality (odds ratio [OR] 3.6), risk of any complication [OR 1.5], and acute renal failure (OR 2.2). There was no increased risk of stroke, wound infection, blood transfusion, or pneumonia. The risk-adjusted length of stay (15 vs 12 days) and cost ($68,000 vs 56,000) were higher in patients with cirrhosis. In conclusion, the presence of cirrhosis poses a significant risk of death in patients who underwent surgical aortic valve replacement. When performed, the cost and length of stay are increased compared with those without cirrhosis.

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Methods

Using methods previously described by our group,14, 15 the Nationwide Inpatient Sample (NIS) Healthcare Cost Utilization Project database was queried from 1998 to 2011 for patients who underwent AVR using the 2003 International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. The database contains individual entries on information regarding demographics, hospital characteristics, co-morbidity, hospital charges, length of

Results

Tables 1 and 2 demonstrate the demographics and co-morbidities between patients with cirrhosis and those without, respectively. The number of aortic valve replacements per year done on patients with cirrhosis more than tripled during our study, from 123 to 388 (Figure 1). That correlated to a jump from 6 per 1,000 cases to 9 per 1,000 cases. The overall mortality rate for patients with cirrhosis was 16%. The yearly mortality rate varied from 10% per year to 34% per year (Figure 1). The

Discussion

The presence of cirrhosis dramatically changes the outcome after isolated surgical aortic valve replacement. Cirrhosis increased the mortality risk by a factor of 3.6, with an overall mortality rate of 16%. More than half of the patients with cirrhosis experienced a complication, with an adjusted odds ratio of 1.5. More than 25% of patients with cirrhosis had postoperative acute renal failure, more than twice the rate of the noncirrhotic matched pairs. In addition, they were more likely to be

Disclosures

The authors have no conflicts of interest to disclose.

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