- Email: [email protected]
Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis
ARTICLE IN PRESS Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis D1X XVikas Singh, D2X XMDa,1,*, D3X XGhanshyambhai T. Savani, D4X XMDb,1, D5X XRodrigo Mendirichaga, D6X XMDc,1, D7X XAnil K. Jonnalagadda, D8X XMDd, D9X XMauricio G. Cohen, D10X XMDe, and D1X XIgor F. Palacios, D12X XMDf Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 § 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 § 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 § 11.4 days and hospitalization cost $67,744.6 § 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years. © 2018 Elsevier Inc. All rights reserved. (Am J Cardiol 2018;00:1−9)
Previously limited to emergency indications, cardiac surgery has been increasingly performed in patients with liver disease in recent years.1 Cardiac surgery carries increased morbidity and mortality in this population and the risk is directly related to the severity of liver disease.1−3 A previous population-based study extending from 1998 to 2004 demonstrated that the annual number of coronary artery bypass graft surgery (CABG) increased by 4.2% in cirrhosis patients. During that study period, patients with cirrhosis were found to have increased risk of morbidity and mortality after CABG.4 Despite available data liver disease is not currently included in cardiac risk assessment models. We sought to present trends in utilization, length of a Division of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky; bDepartment of Medicine, Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts; cDivision of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; dDepartment of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia; eCardiovascular Division, University of Miami Miller School of Medicine, Miami, Massachusetts; and fDivision of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Manuscript received June 20, 2018; revised manuscript received and accepted August 20, 2018. 1 These authors contributed equally to this manuscript. See page 8 for disclosure information. *Corresponding author: Tel: 786-991-8555; fax: 502-852-6233. E-mail address: [email protected] (V. Singh).
0002-9149/© 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amjcard.2018.08.026
stay, hospitalization cost, complications, and in-hospital mortality of patients with cirrhosis who underwent CABG in the United States from 2002 to 2014 and to compare them with noncirrhosis patients.
Methods Data were collected from the Nationwide Inpatient Sample (NIS) database from 2002 to 2014. The NIS database was developed for the Health Care Cost and Utilization Project and has been extensively used to identify, track, and analyze national trends in healthcare.5−7 Subjects were identified using Current Procedural Terminology codes for CABG. Patients selected were then screened by NIS claims by ICD-9-CM codes to identify patients with liver cirrhosis (Figure 1). Patient level characteristics such as age, sex, race, co-morbid conditions, and median household income, primary payer, admission type (urgent and/or emergent vs elective), and day of admission (weekdays vs weekend) were studied. We defined severity of co-morbid conditions using the Deyo modification of the Charlson co-morbidity index.8,9 Hospital level characteristics such as hospital bed size (small, medium, and large), location (urban and/or rural), region (Northeast, Midwest, South, and West), and teaching status were also studied. Facilities were considered teaching hospitals if they had an American Medical Association approved residency program, were a member of the www.ajconline.org
2
Table 1 Baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis who underwent coronary artery bypass grafting in the United States. Overall
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
P trend
173 865 0% 0% 10.40% 23.12% 26.01% 35.26% 5.20% 71.10%
191 955 0% 0% 4.71% 28.27% 35.60% 27.23% 4.19% 68.06%
169 845 0% 0.59% 7.69% 33.73% 34.91% 19.53% 3.55% 72.19%
149 745 0% 0% 2.01% 30.87% 44.30% 20.13% 2.68% 71.14%
185 925 0% 0% 7.57% 28.65% 29.19% 24.32% 10.27% 75.14%
145 725 0% 0.69% 5.52% 29.66% 37.24% 20.69% 6.21% 76.55%
157 785 0% 0.64% 5.73% 34.39% 34.39% 19.75% 5.10% 84.71%
204 1020 0% 0.98% 6.86% 25.98% 38.24% 23.53% 4.41% 73.04%
148 740 0% 1.35% 3.38% 37.84% 36.49% 16.22% 4.73% 78.38%
155 775 0% 0% 6.45% 27.74% 41.94% 19.35% 4.52% 70.32%
160 800 0% 0.63% 6.88% 31.25% 40.00% 18.13% 3.13% 78.75%
199 995 0% 0% 4.02% 26.63% 39.70% 25.63% 4.02% 73.37%
196 980 0% 0% 2.55% 30.61% 36.73% 23.47% 6.63% 76.53%
0.679 0.031 0.537 0.018 0.027 0.954 0.056
57.80% 4.62% 37.57% 2.88 § 1.53 31.79% 28.90% 32.37% 1.73% 6.94%
57.07% 5.76% 37.17% 2.57 § 1.35 29.32% 43.98% 34.03% 1.05% 8.90%
60.95% 4.14% 34.91% 2.70 § 1.32 34.91% 42.01% 32.54% 1.18% 9.47%
55.03% 4.70% 40.27% 2.91 § 1.36 43.62% 54.36% 38.26% 0.67% 14.09%
49.19% 3.78% 47.03% 3.09 § 1.68 32.43% 58.38% 34.59% 3.78% 14.05%
59.31% 6.21% 34.48% 3.02 § 1.51 37.24% 55.86% 29.66% 1.38% 13.10%
61.15% 1.91% 36.94% 3.09 § 1.57 49.68% 66.24% 26.75% 2.55% 16.56%
68.14% 4.41% 27.45% 3.58 § 1.94 51.47% 66.18% 32.84% 2.94% 16.67%
64.86% 4.73% 30.41% 3.32 § 1.83 40.54% 71.62% 29.73% 2.03% 16.22%
69.03% 5.16% 25.81% 3.87 § 2.08 52.26% 74.84% 39.35% 1.29% 20.65%
69.38% 8.13% 22.50% 4.09 § 1.99 52.50% 78.13% 29.38% 1.88% 16.25%
71.86% 5.53% 22.61% 3.78 § 2.10 59.30% 73.37% 35.18% 1.51% 17.59%
75.51% 6.12% 18.37% 3.96 § 2.09 56.63% 73.98% 35.20% 2.04% 17.86%
<0.001 0.268 <0.001
4.62% 6.94% 36.42%
4.71% 6.81% 24.61%
7.69% 5.92% 34.91%
7.38% 5.37% 32.21%
8.11% 5.41% 36.22%
9.66% 6.90% 30.34%
13.38% 8.92% 25.48%
15.20% 6.86% 28.92%
18.92% 12.16% 33.11%
17.42% 11.61% 34.19%
15.63% 10.63% 33.13%
27.64% 12.06% 29.15%
26.53% 11.22% 28.57%
<0.001 <0.001 0.458
8.67% 16.18%
5.24% 17.28%
8.28% 24.26%
11.41% 22.15%
18.92% 26.49%
21.38% 27.59%
15.92% 33.12%
15.69% 35.78%
14.86% 38.51%
18.71% 40.65%
26.88% 46.25%
24.62% 42.21%
20.41% 42.35%
<0.001 <0.001
3.47%
2.62%
4.73%
4.03%
2.70%
5.52%
3.82%
4.90%
3.38%
6.45%
8.13%
6.03%
6.63%
0.007
36.99%
36.65%
43.79%
37.58%
40.54%
51.72%
52.23%
65.20%
54.05%
62.58%
58.13%
62.81%
61.73%
<0.001
0%
0%
0%
0%
0.54%
0%
0.64%
0%
0.68%
0%
0.63%
0%
0%
0.644
26.59%
18.85%
30.77%
34.23%
36.22%
29.66%
35.67%
33.33%
41.22%
38.06%
38.13%
37.19%
40.31%
<0.001
4.62%
2.09%
1.78%
4.03%
3.78%
1.38%
3.82%
2.94%
2.70%
5.16%
3.75%
5.03%
5.10%
0.116
2.89% 19.65% 18.50% 52.60%
26.18% 36.65% 18.85% 17.28%
28.99% 29.59% 19.53% 18.93%
29.53% 22.82% 26.17% 16.78%
26.49% 22.70% 31.35% 17.84%
22.76% 24.14% 28.28% 22.07%
25.48% 29.94% 22.29% 17.20%
26.96% 28.92% 28.43% 13.24%
31.08% 28.38% 22.30% 15.54%
32.90% 22.58% 24.52% 16.13%
35.00% 21.88% 20.00% 20.63%
29.15% 26.63% 25.63% 17.09%
29.59% 26.02% 21.43% 20.41%
<0.001 0.497 0.43 <0.001
<0.001 <0.001 0.527 0.647 <0.001
(continued on next page)
ARTICLE IN PRESS
2002
The American Journal of Cardiology (www.ajconline.org)
Number of cases 2231 National estimate 11155 18-29 years 0% 30-39 years 0.36% 40-49 years 5.69% 50-59 years 29.67% 60-69 years 36.40% 70-79 years 22.86% ≥ 80 years 5.02% Male 74.41% Race White 63.25% Black 5.02% Others 31.73% Charlson score 3.31 § 1.82 Diabetes mellitus 44.20% Hypertension 60.60% Heart failure 33.17% Valvular disease 1.88% Peripheral vascular 14.48% disease Obesity 13.85% Hypothyroidism 8.52% Chronic pulmonary 31.20% disease Renal failure 16.23% Fluid and electro31.82% lytes imbalance Neurological disor4.80% der or paralysis Anemia or 51.32% coagulopathy Acquired immunode0.18% ficiency syndrome Depression or sub33.75% stance abuse Malignancy 3.59% Median household income 1st quartile 26.62% 2nd quartile 26.31% 3rd quartile 23.67% 4th quartile 20.39%
Table 1 (Continued) Overall
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
P trend
65.32%
62.30%
62.72%
69.13%
66.49%
63.45%
62.42%
63.73%
60.14%
64.52%
63.75%
62.81%
72.96%
0.479
30.06% 4.62%
29.32% 8.38%
29.59% 7.69%
24.16% 6.71%
27.03% 6.49%
27.59% 8.97%
28.66% 8.92%
32.84% 3.43%
29.73% 10.14%
26.45% 9.03%
26.88% 9.38%
27.14% 10.05%
20.92% 6.12%
0.158 0.268
3.47% 15.61% 80.92%
5.24% 18.32% 76.44%
5.33% 16.57% 78.11%
5.37% 19.46% 75.17%
2.70% 23.78% 73.51%
6.90% 17.93% 75.17%
5.10% 11.46% 83.44%
3.92% 17.16% 74.02%
7.43% 16.22% 75.00%
4.52% 14.84% 80.65%
6.88% 13.75% 79.38%
4.02% 22.11% 73.87%
7.14% 25.00% 67.86%
0.255 0.264 0.076
4.05% 95.95%
3.66% 96.34%
4.73% 95.27%
0.67% 99.33%
2.70% 97.30%
2.07% 97.93%
3.82% 96.18%
0.98% 94.12%
6.76% 91.89%
2.58% 97.42%
-
-
-
0.746 0.746
17.34% 20.81% 39.31% 22.54%
17.80% 19.90% 48.17% 14.14%
20.12% 16.57% 44.38% 18.93%
18.12% 15.44% 44.97% 21.48%
20.00% 19.46% 41.08% 19.46%
17.24% 20.69% 44.83% 17.24%
15.92% 24.20% 38.85% 21.02%
13.73% 25.49% 44.12% 16.67%
13.51% 23.65% 42.57% 20.27%
14.19% 16.13% 52.90% 16.77%
12.50% 20.63% 49.38% 17.50%
15.08% 20.60% 46.73% 17.59%
13.78% 20.41% 45.92% 19.90%
0.014 0.447 0.142 0.733
34.10% 65.90%
37.70% 62.30%
37.28% 62.72%
41.61% 58.39%
35.68% 64.32%
33.10% 66.90%
38.85% 61.15%
31.86% 63.24%
35.81% 62.84%
35.48% 64.52%
-
-
-
0.534 0.534
17.34% 82.66%
9.42% 90.58%
11.83% 88.17%
13.42% 86.58%
11.89% 88.11%
11.03% 88.97%
12.10% 87.90%
10.29% 89.71%
8.11% 91.89%
10.97% 89.03%
-
-
-
0.091 0.091
90.75% 9.25% 11.56%
88.48% 11.52% 8.38%
89.94% 10.06% 12.43%
85.23% 14.77% 4.03%
93.51% 6.49% 7.03%
93.10% 6.90% 4.83%
88.54% 11.46% 5.10%
92.16% 7.84% 6.37%
87.84% 12.16% 5.41%
90.32% 9.68% 3.87%
86.25% 13.75% 5.63%
88.94% 11.06% 3.52%
84.18% 15.82% 5.10%
0.104 0.104 <0.001
2.89% 9.25%
4.19% 9.95%
5.33% 11.24%
2.68% 11.41%
3.78% 9.19%
3.45% 9.66%
3.82% 7.64%
6.86% 8.82%
6.76% 14.19%
5.81% 9.68%
10.00% 11.25%
8.04% 8.54%
8.16% 9.18%
<0.001 0.848
0%
0%
0%
0%
0%
0%
0%
0.49%
0%
0%
0%
0%
0%
0.807
0%
0%
0%
0%
0%
0%
0%
0.49%
0%
0%
0%
0%
0%
0.807
0%
0%
0%
0%
0%
0%
0%
0%
0.68%
0%
0%
0%
0.51%
0.146
71.68%
70.16%
65.68%
65.10%
70.27%
70.34%
57.96%
71.08%
77.03%
71.61%
71.88%
79.90%
77.55%
0.002
69642.46 § 62874.61
77290.14 § 67342.41
77819.15 § 75833.81
71469.27 § 58633.39
72317.27 § 63926.70
70508.68 § 58065.89
61648.23 § 43465.00
69182.54 § 60717.02
67115.33 § 55026.32
73921.75 § 66785.93
63288.95 § 57719.31
55173.36 § 37394.67
58525.24 § 44253.99
3
(continued on next page)
ARTICLE IN PRESS
2002
Coronary Artery Disease/CABG in Cirrhosis
Primary payer Medicare/ 64.68% Medicaid Private 27.75% 7.58% Uninsured/Self/ No pay Hospital bed size Small 5.15% Medium 18.11% Large 76.20% Hospital location Rural 2.38% Urban 72.21% Hospital region Northeast 16.09% Midwest 20.39% South 44.87% West 18.65% Hospital teaching status Non-teaching 27.07% Teaching* 47.51% Admission type Elective 33.62% Non-elective 66.38% Admission Day Weekday 89.20% Weekend 10.80% ST- elevation myo6.45% cardial infarction Cardiogenic shock 5.60% Intra-aortic balloon 9.91% pump Surgical ventricular 0.04% assist device 0.04% Percutaneous ventricular assist device Extra-corporeal 0.09% membrane oxygenation Cardiopulmonary 71.04% bypass Cost (in 2011 terms; 67744.56 § US dollars) 58320.36
ARTICLE IN PRESS
31.63% 60.71% 7.65% 33.17% 61.31% 5.53% 36.88% 56.88% 6.25% 40.65% 56.13% 3.23% 39.86% 54.05% 6.08% 39.22% 51.96% 8.82% 45.22% 48.41% 6.37% 28.65% 60.54% 10.27% Disposition Home Facility Death
38.77% 52.22% 8.70%
47.40% 41.04% 11.56%
40.31% 42.41% 15.18%
43.20% 44.97% 11.83%
40.27% 51.68% 6.71%
41.38% 46.21% 12.41%
P trend 13.11 § 10.08
2014 2013
12.21 § 8.42 12.88 § 10.21
2012 2011
13.02 § 9.08 12.89 § 11.20
2010 2009
12.61 § 9.43 12.96 § 11.84
2008 2007
13.32 § 9.11
2006
14.21 § 12.51
2005
16.08 § 15.35
2004
15.18§ 12.18
2003
15.47 § 13.00
2002
14.89 § 13.92
Overall
13.74 § 11.42 Length of stay (days)
Table 1 (Continued)
* Facilities were considered teaching hospitals if they had an American Medical Association approved residency program, were a member of the Council of Teaching Hospitals, or had a fulltime equivalent intern and resident to patient ratio of 0.25 or higher.
The American Journal of Cardiology (www.ajconline.org)
0.005 <0.001 <0.001
4
Council of Teaching Hospitals, or had a fulltime equivalent intern and resident to patient ratio of 0.25 or higher. Preventable procedural complications were identified by Patient Safety Indicators (PSI) established by the Agency for Healthcare Research and Quality to monitor preventable adverse events during hospitalization. These indicators are based on ICD-9-CM codes and Medicare severity diagnosis-related groups and each PSI has specific inclusion and exclusion criteria. PSI individual technical specifications were used to identify and define preventable procedural complications (postprocedure deep vein thrombosis, procedural infectious complications including postprocedure sepsis and central venous catheter-related bloodstream infection, and accidental puncture or laceration). An extensive propensity-score matching was performed in a 1:2 ratio through Greedy Method for propensity.10 Matching variables were selected based on univariate regression and clinical significance and included age, gender, race, diabetes, hypertension, peripheral vascular disease, ST-elevation myocardial infarction at presentation, concomitant valve surgery, congestive heart failure, stroke, long-term lung disease, renal failure, neurologic disease, anemia, blood coagulation disorder, obesity, hypothyroidism, collagen vascular disease, acquired immunodeficiency syndrome, alcoholism, drug abuse, weight loss, use of hemodynamic support, use of cardiopulmonary bypass (CBP), admission type (elective vs emergent), and insurance status. Multivariate logistic regression analyses were generated to identify the independent predictors of in-hospital mortality, postoperative complications, length of stay, and hospital cost. Differences in categorical variables were tested using the chi-square test and differences in continuous variables were tested using student’s t test. For categorical variables, chi-square test of trend for proportions was used through the Cochrane Armitage test. For continuous variables, nonparametric test for trend by Cuzick was used. Level of significance was set at p <0.05. Stata IC 12.0 (Stata-Corp) and SAS 9.3 (SAS Institute, Inc.) were utilized for statistical analyses. Results We identified a total of 698,799 patients who underwent CABG of which 2,231 (0.3%) had cirrhosis. Trends in baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis who underwent CABG across the study period are presented in Table 1. Notably, in-hospital mortality decreased significantly in recent years (2002 to 2007: 11.3% vs 2008 to 2014: 6.3%; p <0.001; Figure 2). A comparison of baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis and noncirrhosis patients is presented in Table 2. Patients with cirrhosis had a mean age of age 63.6 § 9.6, were mostly men (74%), white (63%), and had a mean Charlson Co-morbidity Index of 3.3 § 1.8. CPB was used in a high proportion of patients (71%). Most patients presented to large, urban, teaching institutions. Concomitant valve surgery was performed in 18.8% of the cirrhosis patients and 14.2% of the noncirrhosis patients. Compared with noncirrhosis patients, patients with cirrhosis were
ARTICLE IN PRESS Coronary Artery Disease/CABG in Cirrhosis
5
and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). Discussion
Figure 1. Patient selection flow chart.
younger and presented as elective cases more frequently; but had more co-morbidities, higher rates of cardiogenic shock and a higher in-hospital mortality. Length of stay and hospitalization cost were also higher for patients with cirrhosis. Postoperative complications seen in patients with cirrhosis who underwent CABG are summarized in Table 3. Of a total of 2,231 cases, 987 patients experienced a complication. Bleeding requiring transfusion was the most common complication, followed by respiratory failure and iatrogenic cardiac complications. Propensity-score matching in a 1:2 ratio is presented in Table 4. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p <0.001) and in-hospital mortality (7.2% vs 4.07%; p <0.001) than noncirrhosis patients. We performed multivariate logistic regression analyses to identify predictors of in-hospital mortality, postoperative complications, length of stay, and hospitalization cost (Supplementary Tables 1−4). Presence of cirrhosis
We present the largest nationwide cohort of patients with cirrhosis who underwent CABG in the United States. Patients with cirrhosis constitute only a small portion of patients who underwent CABG but have more baseline comorbidities and experience a higher rate of postoperative complications and in-hospital mortality than noncirrhosis patients. Length of stay and hospitalization cost are also increased in patients with cirrhosis. In-hospital mortality remains high for this subgroup of patients but has decreased in recent years. Physiologic challenges associated with cardiac surgery including anesthesia, hypotension, hypoperfusion, coagulopathy, hemorrhage, and large volume transfusion are amplified and poorly tolerated in patients with liver disease. Increased levels of catecholamine release during CPB decrease hepatic perfusion which in turn leads to further catecholamine release and formation of free radicals and vasoactive peptides.11 Visceral ischemia-reperfusion injury is potentiated by the presence of arterial atherosclerosis. Ischemia-induced loss of intestinal barrier results in small bowel injury, bacterial translocation, endotoxin absorption, and the potential development of the systemic inflammatory response syndrome.12 Factor XII activation through contact with the CPB tubing stimulates the intrinsic coagulation pathway and microemboli formation within the tubing can be seen, leading some investigators to propose avoiding CPB in an attempt to improve outcomes in patients with liver disease who underwent cardiac surgery.2,13−16 In our study, CPB was used in most cases and its use remained high throughout the years studied. Interestingly, its use was associated with decreased in-hospital mortality.
Figure 2. Trends of in-hospital mortality of patients with cirrhosis who underwent coronary artery bypass graft surgery in the United States.
ARTICLE IN PRESS 6
The American Journal of Cardiology (www.ajconline.org)
Table 2 Comparison of baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis and patients without cirrhosis who underwent coronary artery bypass grafting
Number of cases National estimate (number) Age in years 18-29 years 30-39 years 40-49 years 50-59 years 60-69 years 70-79 years ≥ 80 years Male Race White Black Others Charlson score Diabetes mellitus Hypertension Congestive heart failure Valvular disease Peripheral vascular disease Obesity Hypothyroidism Chronic pulmonary disease Renal failure Fluid and electrolytes imbalance Neurological disorder or paralysis Anemia or coagulopathy Acquired Immunodeficiency Syndrome Depression or substance abuse Malignancy Median household income 1st quartile 2nd quartile 3rd quartile 4th quartile Primary payer Medicare/Medicaid Private Uninsured/Self/No pay Hospital bed size Small Medium Large Hospital location Rural Urban Hospital region Northeast
Cirrhosis
No Cirrhosis
P value
2231 11155
696568 3482840
63.58 § 9.6 0% 0.36% 5.69% 29.67% 36.40% 22.86% 5.02% 74.41%
66 § 10.85 0.07% 0.83% 6.47% 20.63% 31.69% 29.77% 10.55% 71.58%
63.25% 5.02% 31.73% 3.31 § 1.82 44.20% 60.60% 33.17% 1.88% 14.48%
63.12% 4.99% 31.89% 1.50 § 1.39 36.40% 69.71% 22.43% 0.61% 13.39%
<0.001 <0.001 <0.001 <0.001 0.140
13.85% 8.52% 31.20%
14.77% 7.77% 21.49%
0.209 0.196 <0.001
16.23% 31.82%
10.33% 21.19%
<0.001 <0.001
4.80%
3.87%
0.025
51.32% 0.07%
25.31% 0.18%
<0.001 0.058
33.75%
8.88%
<0.001
3.59%
2.02%
<0.001 <0.001
26.62% 26.31% 23.67% 20.39%
23.54% 25.95% 24.27% 23.72%
92.42% 7.58% 0%
93.46% 6.54% 0%
5.15% 18.11% 76.20%
7.08% 19.34% 73.21%
2.38% 72.21%
3.37% 79.00%
16.09%
16.59%
<0.001
0.003 0.987
0.049
<0.001
0.062
0.001 (continued)
Table 2 (Continued)
Midwest South West Hospital teaching status Nonteaching Teaching Admission type Elective Non-elective Admission Day Weekday Weekend ST-elevation myocardial infarction Cardiogenic shock Intra-aortic balloon pump Surgical ventricular assist device Percutaneous ventricular assist device Extra-corporeal membrane oxygenation Cardiopulmonary bypass Cost (in 2011 terms; in US dollars) Length of stay (days) Disposition Home Facility Death
Cirrhosis
No Cirrhosis
P value
20.39% 44.87% 18.65%
23.51% 43.21% 16.69%
27.07% 47.51%
34.24% 48.13%
33.62% 66.38%
24.23% 75.77%
89.20% 10.80% 6.45%
89.75% 10.25% 8.91%
<0.001
5.60% 9.91%
3.76% 9.13%
<0.001 <0.001
0.04%
0.05%
0.836
0.04%
0.10%
0.409
0.09%
0.10%
0.933
71.04% 67744.56 § 58320.36 13.74 § 11.42
76.67% 50084 § 37946.44
<0.001 <0.001
9.87 § 8.26
<0.001 <0.001
38.77% 52.22% 8.70%
47.45% 49.55% 2.82%
<0.001
0.390
Postoperative complications are commonly seen in patients with cirrhosis who underwent cardiac surgery.17 Previous studies have documented complication rates ranging from 28% to 69%.4,16,18,19 Common complications include bleeding, respiratory failure, infection, and deep venous thrombosis. Postoperative complications were common in our study, including hemorrhage requiring transfusion, respiratory failure, acute renal failure requiring dialysis, infections, and pressure ulcers. Predictors of postoperative complications included cirrhosis, ascites, Charlson score ≥ 2, use of intra-aortic balloon pump, cardiogenic shock, and concomitant valve surgery. In-hospital mortality remains high for patients with cirrhosis who underwent CABG ranging from 7% to 17% in previous studies.4,16−19 Previously described predictors of mortality include EuroSCORE, advanced age, central venous pressure, thrombocytopenia, total bilirubin, CPB time, and total operative time.17 In our study, in-hospital mortality remained elevated but decreased significantly in recent years. Predictors of in-hospital mortality included presence of postoperative complications, ST-elevation myocardial infarction, cirrhosis, ascites, age, female gender, black gender, use of intra-aortic balloon pump, cardiogenic shock, and concomitant valve surgery. Meanwhile, CPB had a protective effect. Current liver disease prediction models like the ChildTurcotte-Pugh classification and the Model for End-stage Liver Disease score have been previously used to predict
Table 3 Complications in patients with cirrhosis who underwent coronary artery bypass grafting in the United States 2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
P trend
2,231 987 16.00% 14.52%
173 65 9.25% 8.09%
191 74 7.85% 6.81%
169 54 12.43% 11.24%
149 63 8.72% 7.38%
185 71 10.27% 9.19%
145 62 12.41% 10.34%
157 68 11.46% 9.55%
204 89 13.73% 12.25%
148 67 18.92% 15.54%
155 88 30.32% 28.39%
160 81 24.38% 23.13%
199 97 24.62% 24.12%
196 108 23.47% 21.94%
<0.001 <0.001 <0.001
2.06%
1.16%
1.05%
1.78%
2.01%
2.16%
2.76%
3.18%
1.47%
4.05%
1.94%
3.13%
1.01%
2.04%
0.436
14.75% 0.49%
19.65% 0%
16.23% 0%
12.43% 0%
14.09% 0%
11.35% 0%
14.48% 0%
11.46% 0%
12.75% 0%
10.81% 0%
15.48% 0%
14.38% 2.50%
15.08% 1.51%
21.94% 2.04%
0.537 <0.001
10.09%
17.34%
12.04%
8.28%
10.74%
6.49%
9.66%
7.64%
7.35%
7.43%
11.61%
8.13%
9.55%
14.29%
0.402
1.34% 2.02% 0.58%
2.31% 0.58% 0.00%
2.09% 1.57% 0.52%
1.78% 1.18% 0.59%
0.67% 1.34% 0%
1.62% 2.16% 0%
1.38% 2.07% 0%
0% 1.27% 1.27%
2.94% 2.94% 0.98%
0.68% 2.03% 0%
0% 1.94% 0.65%
0.63% 1.25% 1.88%
1.51% 2.01% 0.50%
1.02% 5.10% 1.02%
0.150 0.018 0.079
1.70%
2.89%
3.14%
1.78%
0.67%
2.70%
2.76%
0.64%
1.47%
1.35%
1.94%
0.63%
1.51%
0.51%
0.031
0.81% 12.73% 1.79% 13.00% 2.20%
0.58% 13.87% 2.31% 9.83% 4.05%
0.52% 19.37% 2.62% 13.09% 6.81%
0.59% 8.88% 1.18% 8.28% 2.37%
2.01% 10.07% 2.01% 9.40% 0.67%
0.54% 12.43% 2.16% 7.03% 6.49%
0.69% 15.17% 0.69% 12.41% 5.52%
1.91% 14.01% 3.82% 12.74% 2.55%
0.49% 8.33% 1.47% 11.27% 0%
0.68% 7.43% 1.35% 10.14% 0%
0.65% 12.26% 2.58% 14.19% 0%
0% 16.25% 0% 25.00% 0%
0.50% 13.07% 1.01% 19.10% 0%
1.53% 13.78% 2.04% 15.82% 0%
0.959 0.637 0.305 <0.001 <0.001
1.97%
0.58%
2.62%
1.78%
3.36%
1.62%
2.07%
1.91%
2.45%
2.70%
1.29%
1.25%
2.51%
1.53%
0.996
2.38% 2.06%
0.58% 0.58%
2.09% 1.57%
1.78% 1.78%
2.68% 2.01%
1.62% 1.62%
3.45% 3.45%
5.10% 4.46%
1.47% 1.47%
2.03% 1.35%
0.65% 0.65%
1.88% 1.88%
2.51% 2.51%
5.10% 3.57%
0.106 0.199
0.31%
0.00%
0.52%
0%
0.67%
0%
0%
0.64%
0%
0.68%
0%
0%
0%
1.53%
0.254
1.39%
2.89%
0.52%
2.37%
0%
1.08%
1.38%
0.64%
1.47%
1.35%
0%
2.50%
2.01%
1.53%
0.925
6.28% 8.43%
7.51% 0.58%
4.71% 2.62%
5.92% 3.55%
4.70% 10.07%
6.49% 8.11%
4.83% 8.28%
5.10% 12.10%
8.82% 10.29%
5.41% 14.86%
7.74% 10.32%
5.63% 14.38%
8.04% 7.54%
5.61% 9.18%
0.525 <0.001
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Coronary Artery Disease/CABG in Cirrhosis
Total cases with cirrhosis Complications (number of cases) Vascular complications Hemorrhage requiring transfusion Other vascular complications including Cardiac complications Post-operative cardiogenic shock Iatrogenic cardiac complications Complete heart block Other heart block Temporary pacemaker placement Permanent pacemaker placement Pericardial complications Respiratory complications Iatrogenic pneumothorax Respiratory failure Other iatrogenic respiratory complications Neurological complications (stroke or transient ischemic attack) Renal and metabolic complications Acute renal failure requiring dialysis Acute severe metabolic derangement Deep vein thrombosis or pulmonary embolism Infectious complications Pressure ulcers
Overall
7
ARTICLE IN PRESS 8
The American Journal of Cardiology (www.ajconline.org)
Table 4 Propensity-score matching in a 1:2 ratio
Actual cases (number) Mortality Overall complications rate Vascular complications Hemorrhage requiring transfusion Other vascular complications including Cardiac complications Iatrogenic cardiac complications Complete heart block Other heart block Temporary pacemaker placement Permanent pacemaker placement Pericardial complications Respiratory complications Iatrogenic pneumothorax Respiratory failure Other iatrogenic respiratory complications Neurological complications Deep vein thrombosis or pulmonary embolism Infectious complications Pressure ulcers
Cirrhosis
No Cirrhosis
P value
1,084 7.21% 43.91% 16.13% 14.62% 2.12%
2,168 4.07 38.93% 12.33% 10.55% 2.14%
<0.001 0.006 <0.001 <0.001 0.947
15.59% 9.32% 1.48% 2.31% 0.55% 1.69% 0.83% 11.72% 1.94% 11.9% 1.81%
13.93% 10.01% 1.52% 2.58% 0.74% 1.6% 1.06% 9.32% 1.75% 9.27% 2.03%
0.212 0.306 0.919 0.633 0.545 0.758 0.53 0.032 0.71 0.019 0.721
1.94% 0.92%
1.71% 1.38%
0.639 0.261
6.09% 9.78%
4.89% 2.12%
0.15 <0.001
outcomes in patients with liver disease who underwent cardiac surgery.2,3,20,21 Child-Turcotte-Pugh scores >7 (class B or C) and Model for End-stage Liver Disease scores >13 have been suggested as "thresholds" beyond which mortality increased significantly. The optimal revascularization strategy for patients with advanced liver disease remains unknown. The use of off-pump CABG has yielded conflicting results. Full percutaneous revascularization has also been proposed as an alternative.19,22,23 Bare metal stents have been frequently used in patients with cirrhosis to avoid the need for prolonged use of dual antiplatelets. However, a recent study demonstrated that the use of bare metal stents (as opposed to drug-eluting stents) in patients with advanced liver disease does not decrease bleeding rates in the short term and is associated with increased in-hospital mortality.24 Ultimately, adequate patient selection and preoperative risk stratification with the combined use of conventional cardiac risk scores and liver disease models may lead to reduced improved outcomes. The large case volume, inclusive nature, and heterogeneity of our data are important strengths that offer an insight into the outcomes of patients with cirrhosis who underwent CABG in a “real-world” scenario. Nevertheless, some limitations are worth noting: (1) absence of certain patient characteristics including laboratory findings hinder calculation of liver prediction models and thus diagnosis of cirrhosis relies on coding (with the possibility for miscoding); (2) some procedural characteristics are not reported (i.e., CPB times) precluding further analysis of the impact of these variables; and lastly (3) selection bias may be present as patients who were managed medically or with PCI are not included in our analysis.
In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States. Postoperative complications are common, and in-hospital mortality remains high but has decreased in recent years. The presence of cirrhosis should be taken into consideration along with traditional cardiac risk assessment models before selecting the ideal approach to revascularization. Disclosures The authors have no conflicts of interest to disclose. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.amj card.2018.08.026.
1. Diaz GC, Renz JF. Cardiac surgery in patients with end-stage liver disease. J Cardiothorac Vasc Anesth 2014;28:155–162. 2. Filsoufi F, Salzberg SP, Rahmanian PB, Schiano TD, Elsiesy H, Squire A, Adams DH. Early and late outcome of cardiac surgery in patients with liver cirrhosis. Liver Transpl 2007;13:990–995. 3. Murata M, Kato TS, Kuwaki K, Yamamoto T, Dohi S, Amano A. Preoperative hepatic dysfunction could predict postoperative mortality and morbidity in patients undergoing cardiac surgery: utilization of the MELD scoring system. Int J Cardiol 2016;203:682–689. 4. Shaheen AA, Kaplan GG, Hubbard JN, Myers RP. Morbidity and mortality following coronary artery bypass graft surgery in patients with cirrhosis: a population-based study. Liver Int 2009;29:1141–1151. 5. (NIS) HNIS. Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality, 2002−2011. 6. (NIS) HNIS. Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality, 2012−2014. 7. Singh V, Mendirichaga R, Savani GT, Rodriguez AP, Dabas N, Munagala A, Alfonso CE, Cohen MG, Elmariah S, Palacios IF. Coronary revascularization for acute myocardial infarction in the HIV population. J Interv Cardiol 2017;30:405–414. 8. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383. 9. Singh V, Badheka AO, Patel SV, Patel NJ, Thakkar B, Patel N, Arora S, Patel N, Patel A, Savani C, Ghatak A, Panaich SS, Jhamnani S, Deshmukh A, Chothani A, Sonani R, Patel A, Bhatt P, Dave A, Bhimani R, Mohamad T, Grines C, Cleman M, Forrest JK, Mangi A. Comparison of Inhospital Outcomes of surgical aortic valve replacement in hospitals with and without availability of a transcatheter aortic valve implantation program (from a Nationally Representative Database). Am J Cardiol 2015;116:1229–1236. 10. LS P. Reducing bias in a propensity score matched-pair sample using greedy matching techniques. In: Cary N, ed. Proceedings of the twenty-sixth annual SAS users group international conference: SAS Institute; 2001. 11. Reves JG, Karp RB, Buttner EE, Tosone S, Smith LR, Samuelson PN, Kreusch GR, Oparil S. Neuronal and adrenomedullary catecholamine release in response to cardiopulmonary bypass in man. Circulation 1982;66:49–55. 12. Diaz GC, Moitra V, Sladen RN. Hepatic and renal protection during cardiac surgery. Anesthesiol Clin 2008;26:565–590. 13. Gaudino M, Santarelli P, Bruno P, Piancone FL, Possati G. Palliative coronary artery surgery in patients with severe noncardiac diseases. Am J Cardiol 1997;80:1351–1352. 14. Kaplan M, Cimen S, Kut MS, Demirtas MM. Cardiac operations for patients with chronic liver disease. Heart Surg Forum 2002;5:60–65. 15. Hayashida N, Shoujima T, Teshima H, Yokokura Y, Takagi K, Tomoeda H, Aoyagi S. Clinical outcome after cardiac operations in patients with cirrhosis. Ann Thorac Surg 2004;77:500–505. 16. Gopaldas RR, Chu D, Cornwell LD, Dao TK, Lemaire SA, Coselli JS, Bakaeen FG. Cirrhosis as a moderator of outcomes in coronary artery
ARTICLE IN PRESS Coronary Artery Disease/CABG in Cirrhosis
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20.
bypass grafting and off-pump coronary artery bypass operations: a 12year population-based study. Ann Thorac Surg 2013;96:1310–1315. Lopez-Delgado JC, Esteve F, Javierre C, Ventura JL, Manez R, Farrero E, Torrado H, Rodriguez-Castro D, Carrio ML. Influence of cirrhosis in cardiac surgery outcomes. World J Hepatol 2015;7:753–760. Lin CH, Hsu RB. Cardiac surgery in patients with liver cirrhosis: risk factors for predicting mortality. World J Gastroenterol 2014;20:12608–12614. Marui A, Kimura T, Tanaka S, Miwa S, Yamazaki K, Minakata K, Nakata T, Ikeda T, Furukawa Y, Kita T, Sakata R. Coronary revascularization in patients with liver cirrhosis. Ann Thorac Surg 2011;91:1393–1399. Suman A, Barnes DS, Zein NN, Levinthal GN, Connor JT, Carey WD. Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of child-pugh and MELD scores. Clin Gastroenterol Hepatol 2004;2:719–723.
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21. Morimoto N, Okada K, Okita Y. The model for end-stage liver disease (MELD) predicts early and late outcomes of cardiovascular operations in patients with liver cirrhosis. Ann Thorac Surg 2013;96:1672–1678. 22. Azarbal B, Poommipanit P, Arbit B, Hage A, Patel J, Kittleson M, Kar S, Kaldas FM, Busuttil RW. Feasibility and safety of percutaneous coronary intervention in patients with end-stage liver disease referred for liver transplantation. Liver Transpl 2011;17:809–813. 23. Pillarisetti J, Patel P, Duthuluru S, Roberts J, Chen W, Genton R, Wiley M, Candipan R, Tadros P, Gupta K. Cardiac catheterization in patients with end-stage liver disease: safety and outcomes. Catheter Cardiovasc Interv 2011;77:45–48. 24. Singh V, Patel NJ, Rodriguez AP, Shantha G, Arora S, Deshmukh A, Cohen MG, Grines C, De Marchena E, Badheka A, Ghatak A. Percutaneous coronary intervention in patients with end-stage liver disease. Am J Cardiol 2016;117:1729–1734.
Previously limited to emergency indications, cardiac surgery has been increasingly performed in patients with liver disease in recent years.1 Cardiac surgery carries increased morbidity and mortality in this population and the risk is directly related to the severity of liver disease.1−3 A previous population-based study extending from 1998 to 2004 demonstrated that the annual number of coronary artery bypass graft surgery (CABG) increased by 4.2% in cirrhosis patients. During that study period, patients with cirrhosis were found to have increased risk of morbidity and mortality after CABG.4 Despite available data liver disease is not currently included in cardiac risk assessment models. We sought to present trends in utilization, length of a Division of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky; bDepartment of Medicine, Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts; cDivision of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; dDepartment of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia; eCardiovascular Division, University of Miami Miller School of Medicine, Miami, Massachusetts; and fDivision of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Manuscript received June 20, 2018; revised manuscript received and accepted August 20, 2018. 1 These authors contributed equally to this manuscript. See page 8 for disclosure information. *Corresponding author: Tel: 786-991-8555; fax: 502-852-6233. E-mail address: [email protected] (V. Singh).
0002-9149/© 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amjcard.2018.08.026
stay, hospitalization cost, complications, and in-hospital mortality of patients with cirrhosis who underwent CABG in the United States from 2002 to 2014 and to compare them with noncirrhosis patients.
Methods Data were collected from the Nationwide Inpatient Sample (NIS) database from 2002 to 2014. The NIS database was developed for the Health Care Cost and Utilization Project and has been extensively used to identify, track, and analyze national trends in healthcare.5−7 Subjects were identified using Current Procedural Terminology codes for CABG. Patients selected were then screened by NIS claims by ICD-9-CM codes to identify patients with liver cirrhosis (Figure 1). Patient level characteristics such as age, sex, race, co-morbid conditions, and median household income, primary payer, admission type (urgent and/or emergent vs elective), and day of admission (weekdays vs weekend) were studied. We defined severity of co-morbid conditions using the Deyo modification of the Charlson co-morbidity index.8,9 Hospital level characteristics such as hospital bed size (small, medium, and large), location (urban and/or rural), region (Northeast, Midwest, South, and West), and teaching status were also studied. Facilities were considered teaching hospitals if they had an American Medical Association approved residency program, were a member of the www.ajconline.org
2
Table 1 Baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis who underwent coronary artery bypass grafting in the United States. Overall
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
P trend
173 865 0% 0% 10.40% 23.12% 26.01% 35.26% 5.20% 71.10%
191 955 0% 0% 4.71% 28.27% 35.60% 27.23% 4.19% 68.06%
169 845 0% 0.59% 7.69% 33.73% 34.91% 19.53% 3.55% 72.19%
149 745 0% 0% 2.01% 30.87% 44.30% 20.13% 2.68% 71.14%
185 925 0% 0% 7.57% 28.65% 29.19% 24.32% 10.27% 75.14%
145 725 0% 0.69% 5.52% 29.66% 37.24% 20.69% 6.21% 76.55%
157 785 0% 0.64% 5.73% 34.39% 34.39% 19.75% 5.10% 84.71%
204 1020 0% 0.98% 6.86% 25.98% 38.24% 23.53% 4.41% 73.04%
148 740 0% 1.35% 3.38% 37.84% 36.49% 16.22% 4.73% 78.38%
155 775 0% 0% 6.45% 27.74% 41.94% 19.35% 4.52% 70.32%
160 800 0% 0.63% 6.88% 31.25% 40.00% 18.13% 3.13% 78.75%
199 995 0% 0% 4.02% 26.63% 39.70% 25.63% 4.02% 73.37%
196 980 0% 0% 2.55% 30.61% 36.73% 23.47% 6.63% 76.53%
0.679 0.031 0.537 0.018 0.027 0.954 0.056
57.80% 4.62% 37.57% 2.88 § 1.53 31.79% 28.90% 32.37% 1.73% 6.94%
57.07% 5.76% 37.17% 2.57 § 1.35 29.32% 43.98% 34.03% 1.05% 8.90%
60.95% 4.14% 34.91% 2.70 § 1.32 34.91% 42.01% 32.54% 1.18% 9.47%
55.03% 4.70% 40.27% 2.91 § 1.36 43.62% 54.36% 38.26% 0.67% 14.09%
49.19% 3.78% 47.03% 3.09 § 1.68 32.43% 58.38% 34.59% 3.78% 14.05%
59.31% 6.21% 34.48% 3.02 § 1.51 37.24% 55.86% 29.66% 1.38% 13.10%
61.15% 1.91% 36.94% 3.09 § 1.57 49.68% 66.24% 26.75% 2.55% 16.56%
68.14% 4.41% 27.45% 3.58 § 1.94 51.47% 66.18% 32.84% 2.94% 16.67%
64.86% 4.73% 30.41% 3.32 § 1.83 40.54% 71.62% 29.73% 2.03% 16.22%
69.03% 5.16% 25.81% 3.87 § 2.08 52.26% 74.84% 39.35% 1.29% 20.65%
69.38% 8.13% 22.50% 4.09 § 1.99 52.50% 78.13% 29.38% 1.88% 16.25%
71.86% 5.53% 22.61% 3.78 § 2.10 59.30% 73.37% 35.18% 1.51% 17.59%
75.51% 6.12% 18.37% 3.96 § 2.09 56.63% 73.98% 35.20% 2.04% 17.86%
<0.001 0.268 <0.001
4.62% 6.94% 36.42%
4.71% 6.81% 24.61%
7.69% 5.92% 34.91%
7.38% 5.37% 32.21%
8.11% 5.41% 36.22%
9.66% 6.90% 30.34%
13.38% 8.92% 25.48%
15.20% 6.86% 28.92%
18.92% 12.16% 33.11%
17.42% 11.61% 34.19%
15.63% 10.63% 33.13%
27.64% 12.06% 29.15%
26.53% 11.22% 28.57%
<0.001 <0.001 0.458
8.67% 16.18%
5.24% 17.28%
8.28% 24.26%
11.41% 22.15%
18.92% 26.49%
21.38% 27.59%
15.92% 33.12%
15.69% 35.78%
14.86% 38.51%
18.71% 40.65%
26.88% 46.25%
24.62% 42.21%
20.41% 42.35%
<0.001 <0.001
3.47%
2.62%
4.73%
4.03%
2.70%
5.52%
3.82%
4.90%
3.38%
6.45%
8.13%
6.03%
6.63%
0.007
36.99%
36.65%
43.79%
37.58%
40.54%
51.72%
52.23%
65.20%
54.05%
62.58%
58.13%
62.81%
61.73%
<0.001
0%
0%
0%
0%
0.54%
0%
0.64%
0%
0.68%
0%
0.63%
0%
0%
0.644
26.59%
18.85%
30.77%
34.23%
36.22%
29.66%
35.67%
33.33%
41.22%
38.06%
38.13%
37.19%
40.31%
<0.001
4.62%
2.09%
1.78%
4.03%
3.78%
1.38%
3.82%
2.94%
2.70%
5.16%
3.75%
5.03%
5.10%
0.116
2.89% 19.65% 18.50% 52.60%
26.18% 36.65% 18.85% 17.28%
28.99% 29.59% 19.53% 18.93%
29.53% 22.82% 26.17% 16.78%
26.49% 22.70% 31.35% 17.84%
22.76% 24.14% 28.28% 22.07%
25.48% 29.94% 22.29% 17.20%
26.96% 28.92% 28.43% 13.24%
31.08% 28.38% 22.30% 15.54%
32.90% 22.58% 24.52% 16.13%
35.00% 21.88% 20.00% 20.63%
29.15% 26.63% 25.63% 17.09%
29.59% 26.02% 21.43% 20.41%
<0.001 0.497 0.43 <0.001
<0.001 <0.001 0.527 0.647 <0.001
(continued on next page)
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The American Journal of Cardiology (www.ajconline.org)
Number of cases 2231 National estimate 11155 18-29 years 0% 30-39 years 0.36% 40-49 years 5.69% 50-59 years 29.67% 60-69 years 36.40% 70-79 years 22.86% ≥ 80 years 5.02% Male 74.41% Race White 63.25% Black 5.02% Others 31.73% Charlson score 3.31 § 1.82 Diabetes mellitus 44.20% Hypertension 60.60% Heart failure 33.17% Valvular disease 1.88% Peripheral vascular 14.48% disease Obesity 13.85% Hypothyroidism 8.52% Chronic pulmonary 31.20% disease Renal failure 16.23% Fluid and electro31.82% lytes imbalance Neurological disor4.80% der or paralysis Anemia or 51.32% coagulopathy Acquired immunode0.18% ficiency syndrome Depression or sub33.75% stance abuse Malignancy 3.59% Median household income 1st quartile 26.62% 2nd quartile 26.31% 3rd quartile 23.67% 4th quartile 20.39%
Table 1 (Continued) Overall
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
P trend
65.32%
62.30%
62.72%
69.13%
66.49%
63.45%
62.42%
63.73%
60.14%
64.52%
63.75%
62.81%
72.96%
0.479
30.06% 4.62%
29.32% 8.38%
29.59% 7.69%
24.16% 6.71%
27.03% 6.49%
27.59% 8.97%
28.66% 8.92%
32.84% 3.43%
29.73% 10.14%
26.45% 9.03%
26.88% 9.38%
27.14% 10.05%
20.92% 6.12%
0.158 0.268
3.47% 15.61% 80.92%
5.24% 18.32% 76.44%
5.33% 16.57% 78.11%
5.37% 19.46% 75.17%
2.70% 23.78% 73.51%
6.90% 17.93% 75.17%
5.10% 11.46% 83.44%
3.92% 17.16% 74.02%
7.43% 16.22% 75.00%
4.52% 14.84% 80.65%
6.88% 13.75% 79.38%
4.02% 22.11% 73.87%
7.14% 25.00% 67.86%
0.255 0.264 0.076
4.05% 95.95%
3.66% 96.34%
4.73% 95.27%
0.67% 99.33%
2.70% 97.30%
2.07% 97.93%
3.82% 96.18%
0.98% 94.12%
6.76% 91.89%
2.58% 97.42%
-
-
-
0.746 0.746
17.34% 20.81% 39.31% 22.54%
17.80% 19.90% 48.17% 14.14%
20.12% 16.57% 44.38% 18.93%
18.12% 15.44% 44.97% 21.48%
20.00% 19.46% 41.08% 19.46%
17.24% 20.69% 44.83% 17.24%
15.92% 24.20% 38.85% 21.02%
13.73% 25.49% 44.12% 16.67%
13.51% 23.65% 42.57% 20.27%
14.19% 16.13% 52.90% 16.77%
12.50% 20.63% 49.38% 17.50%
15.08% 20.60% 46.73% 17.59%
13.78% 20.41% 45.92% 19.90%
0.014 0.447 0.142 0.733
34.10% 65.90%
37.70% 62.30%
37.28% 62.72%
41.61% 58.39%
35.68% 64.32%
33.10% 66.90%
38.85% 61.15%
31.86% 63.24%
35.81% 62.84%
35.48% 64.52%
-
-
-
0.534 0.534
17.34% 82.66%
9.42% 90.58%
11.83% 88.17%
13.42% 86.58%
11.89% 88.11%
11.03% 88.97%
12.10% 87.90%
10.29% 89.71%
8.11% 91.89%
10.97% 89.03%
-
-
-
0.091 0.091
90.75% 9.25% 11.56%
88.48% 11.52% 8.38%
89.94% 10.06% 12.43%
85.23% 14.77% 4.03%
93.51% 6.49% 7.03%
93.10% 6.90% 4.83%
88.54% 11.46% 5.10%
92.16% 7.84% 6.37%
87.84% 12.16% 5.41%
90.32% 9.68% 3.87%
86.25% 13.75% 5.63%
88.94% 11.06% 3.52%
84.18% 15.82% 5.10%
0.104 0.104 <0.001
2.89% 9.25%
4.19% 9.95%
5.33% 11.24%
2.68% 11.41%
3.78% 9.19%
3.45% 9.66%
3.82% 7.64%
6.86% 8.82%
6.76% 14.19%
5.81% 9.68%
10.00% 11.25%
8.04% 8.54%
8.16% 9.18%
<0.001 0.848
0%
0%
0%
0%
0%
0%
0%
0.49%
0%
0%
0%
0%
0%
0.807
0%
0%
0%
0%
0%
0%
0%
0.49%
0%
0%
0%
0%
0%
0.807
0%
0%
0%
0%
0%
0%
0%
0%
0.68%
0%
0%
0%
0.51%
0.146
71.68%
70.16%
65.68%
65.10%
70.27%
70.34%
57.96%
71.08%
77.03%
71.61%
71.88%
79.90%
77.55%
0.002
69642.46 § 62874.61
77290.14 § 67342.41
77819.15 § 75833.81
71469.27 § 58633.39
72317.27 § 63926.70
70508.68 § 58065.89
61648.23 § 43465.00
69182.54 § 60717.02
67115.33 § 55026.32
73921.75 § 66785.93
63288.95 § 57719.31
55173.36 § 37394.67
58525.24 § 44253.99
3
(continued on next page)
ARTICLE IN PRESS
2002
Coronary Artery Disease/CABG in Cirrhosis
Primary payer Medicare/ 64.68% Medicaid Private 27.75% 7.58% Uninsured/Self/ No pay Hospital bed size Small 5.15% Medium 18.11% Large 76.20% Hospital location Rural 2.38% Urban 72.21% Hospital region Northeast 16.09% Midwest 20.39% South 44.87% West 18.65% Hospital teaching status Non-teaching 27.07% Teaching* 47.51% Admission type Elective 33.62% Non-elective 66.38% Admission Day Weekday 89.20% Weekend 10.80% ST- elevation myo6.45% cardial infarction Cardiogenic shock 5.60% Intra-aortic balloon 9.91% pump Surgical ventricular 0.04% assist device 0.04% Percutaneous ventricular assist device Extra-corporeal 0.09% membrane oxygenation Cardiopulmonary 71.04% bypass Cost (in 2011 terms; 67744.56 § US dollars) 58320.36
ARTICLE IN PRESS
31.63% 60.71% 7.65% 33.17% 61.31% 5.53% 36.88% 56.88% 6.25% 40.65% 56.13% 3.23% 39.86% 54.05% 6.08% 39.22% 51.96% 8.82% 45.22% 48.41% 6.37% 28.65% 60.54% 10.27% Disposition Home Facility Death
38.77% 52.22% 8.70%
47.40% 41.04% 11.56%
40.31% 42.41% 15.18%
43.20% 44.97% 11.83%
40.27% 51.68% 6.71%
41.38% 46.21% 12.41%
P trend 13.11 § 10.08
2014 2013
12.21 § 8.42 12.88 § 10.21
2012 2011
13.02 § 9.08 12.89 § 11.20
2010 2009
12.61 § 9.43 12.96 § 11.84
2008 2007
13.32 § 9.11
2006
14.21 § 12.51
2005
16.08 § 15.35
2004
15.18§ 12.18
2003
15.47 § 13.00
2002
14.89 § 13.92
Overall
13.74 § 11.42 Length of stay (days)
Table 1 (Continued)
* Facilities were considered teaching hospitals if they had an American Medical Association approved residency program, were a member of the Council of Teaching Hospitals, or had a fulltime equivalent intern and resident to patient ratio of 0.25 or higher.
The American Journal of Cardiology (www.ajconline.org)
0.005 <0.001 <0.001
4
Council of Teaching Hospitals, or had a fulltime equivalent intern and resident to patient ratio of 0.25 or higher. Preventable procedural complications were identified by Patient Safety Indicators (PSI) established by the Agency for Healthcare Research and Quality to monitor preventable adverse events during hospitalization. These indicators are based on ICD-9-CM codes and Medicare severity diagnosis-related groups and each PSI has specific inclusion and exclusion criteria. PSI individual technical specifications were used to identify and define preventable procedural complications (postprocedure deep vein thrombosis, procedural infectious complications including postprocedure sepsis and central venous catheter-related bloodstream infection, and accidental puncture or laceration). An extensive propensity-score matching was performed in a 1:2 ratio through Greedy Method for propensity.10 Matching variables were selected based on univariate regression and clinical significance and included age, gender, race, diabetes, hypertension, peripheral vascular disease, ST-elevation myocardial infarction at presentation, concomitant valve surgery, congestive heart failure, stroke, long-term lung disease, renal failure, neurologic disease, anemia, blood coagulation disorder, obesity, hypothyroidism, collagen vascular disease, acquired immunodeficiency syndrome, alcoholism, drug abuse, weight loss, use of hemodynamic support, use of cardiopulmonary bypass (CBP), admission type (elective vs emergent), and insurance status. Multivariate logistic regression analyses were generated to identify the independent predictors of in-hospital mortality, postoperative complications, length of stay, and hospital cost. Differences in categorical variables were tested using the chi-square test and differences in continuous variables were tested using student’s t test. For categorical variables, chi-square test of trend for proportions was used through the Cochrane Armitage test. For continuous variables, nonparametric test for trend by Cuzick was used. Level of significance was set at p <0.05. Stata IC 12.0 (Stata-Corp) and SAS 9.3 (SAS Institute, Inc.) were utilized for statistical analyses. Results We identified a total of 698,799 patients who underwent CABG of which 2,231 (0.3%) had cirrhosis. Trends in baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis who underwent CABG across the study period are presented in Table 1. Notably, in-hospital mortality decreased significantly in recent years (2002 to 2007: 11.3% vs 2008 to 2014: 6.3%; p <0.001; Figure 2). A comparison of baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis and noncirrhosis patients is presented in Table 2. Patients with cirrhosis had a mean age of age 63.6 § 9.6, were mostly men (74%), white (63%), and had a mean Charlson Co-morbidity Index of 3.3 § 1.8. CPB was used in a high proportion of patients (71%). Most patients presented to large, urban, teaching institutions. Concomitant valve surgery was performed in 18.8% of the cirrhosis patients and 14.2% of the noncirrhosis patients. Compared with noncirrhosis patients, patients with cirrhosis were
ARTICLE IN PRESS Coronary Artery Disease/CABG in Cirrhosis
5
and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). Discussion
Figure 1. Patient selection flow chart.
younger and presented as elective cases more frequently; but had more co-morbidities, higher rates of cardiogenic shock and a higher in-hospital mortality. Length of stay and hospitalization cost were also higher for patients with cirrhosis. Postoperative complications seen in patients with cirrhosis who underwent CABG are summarized in Table 3. Of a total of 2,231 cases, 987 patients experienced a complication. Bleeding requiring transfusion was the most common complication, followed by respiratory failure and iatrogenic cardiac complications. Propensity-score matching in a 1:2 ratio is presented in Table 4. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p <0.001) and in-hospital mortality (7.2% vs 4.07%; p <0.001) than noncirrhosis patients. We performed multivariate logistic regression analyses to identify predictors of in-hospital mortality, postoperative complications, length of stay, and hospitalization cost (Supplementary Tables 1−4). Presence of cirrhosis
We present the largest nationwide cohort of patients with cirrhosis who underwent CABG in the United States. Patients with cirrhosis constitute only a small portion of patients who underwent CABG but have more baseline comorbidities and experience a higher rate of postoperative complications and in-hospital mortality than noncirrhosis patients. Length of stay and hospitalization cost are also increased in patients with cirrhosis. In-hospital mortality remains high for this subgroup of patients but has decreased in recent years. Physiologic challenges associated with cardiac surgery including anesthesia, hypotension, hypoperfusion, coagulopathy, hemorrhage, and large volume transfusion are amplified and poorly tolerated in patients with liver disease. Increased levels of catecholamine release during CPB decrease hepatic perfusion which in turn leads to further catecholamine release and formation of free radicals and vasoactive peptides.11 Visceral ischemia-reperfusion injury is potentiated by the presence of arterial atherosclerosis. Ischemia-induced loss of intestinal barrier results in small bowel injury, bacterial translocation, endotoxin absorption, and the potential development of the systemic inflammatory response syndrome.12 Factor XII activation through contact with the CPB tubing stimulates the intrinsic coagulation pathway and microemboli formation within the tubing can be seen, leading some investigators to propose avoiding CPB in an attempt to improve outcomes in patients with liver disease who underwent cardiac surgery.2,13−16 In our study, CPB was used in most cases and its use remained high throughout the years studied. Interestingly, its use was associated with decreased in-hospital mortality.
Figure 2. Trends of in-hospital mortality of patients with cirrhosis who underwent coronary artery bypass graft surgery in the United States.
ARTICLE IN PRESS 6
The American Journal of Cardiology (www.ajconline.org)
Table 2 Comparison of baseline characteristics, hospital characteristics, and outcomes of patients with cirrhosis and patients without cirrhosis who underwent coronary artery bypass grafting
Number of cases National estimate (number) Age in years 18-29 years 30-39 years 40-49 years 50-59 years 60-69 years 70-79 years ≥ 80 years Male Race White Black Others Charlson score Diabetes mellitus Hypertension Congestive heart failure Valvular disease Peripheral vascular disease Obesity Hypothyroidism Chronic pulmonary disease Renal failure Fluid and electrolytes imbalance Neurological disorder or paralysis Anemia or coagulopathy Acquired Immunodeficiency Syndrome Depression or substance abuse Malignancy Median household income 1st quartile 2nd quartile 3rd quartile 4th quartile Primary payer Medicare/Medicaid Private Uninsured/Self/No pay Hospital bed size Small Medium Large Hospital location Rural Urban Hospital region Northeast
Cirrhosis
No Cirrhosis
P value
2231 11155
696568 3482840
63.58 § 9.6 0% 0.36% 5.69% 29.67% 36.40% 22.86% 5.02% 74.41%
66 § 10.85 0.07% 0.83% 6.47% 20.63% 31.69% 29.77% 10.55% 71.58%
63.25% 5.02% 31.73% 3.31 § 1.82 44.20% 60.60% 33.17% 1.88% 14.48%
63.12% 4.99% 31.89% 1.50 § 1.39 36.40% 69.71% 22.43% 0.61% 13.39%
<0.001 <0.001 <0.001 <0.001 0.140
13.85% 8.52% 31.20%
14.77% 7.77% 21.49%
0.209 0.196 <0.001
16.23% 31.82%
10.33% 21.19%
<0.001 <0.001
4.80%
3.87%
0.025
51.32% 0.07%
25.31% 0.18%
<0.001 0.058
33.75%
8.88%
<0.001
3.59%
2.02%
<0.001 <0.001
26.62% 26.31% 23.67% 20.39%
23.54% 25.95% 24.27% 23.72%
92.42% 7.58% 0%
93.46% 6.54% 0%
5.15% 18.11% 76.20%
7.08% 19.34% 73.21%
2.38% 72.21%
3.37% 79.00%
16.09%
16.59%
<0.001
0.003 0.987
0.049
<0.001
0.062
0.001 (continued)
Table 2 (Continued)
Midwest South West Hospital teaching status Nonteaching Teaching Admission type Elective Non-elective Admission Day Weekday Weekend ST-elevation myocardial infarction Cardiogenic shock Intra-aortic balloon pump Surgical ventricular assist device Percutaneous ventricular assist device Extra-corporeal membrane oxygenation Cardiopulmonary bypass Cost (in 2011 terms; in US dollars) Length of stay (days) Disposition Home Facility Death
Cirrhosis
No Cirrhosis
P value
20.39% 44.87% 18.65%
23.51% 43.21% 16.69%
27.07% 47.51%
34.24% 48.13%
33.62% 66.38%
24.23% 75.77%
89.20% 10.80% 6.45%
89.75% 10.25% 8.91%
<0.001
5.60% 9.91%
3.76% 9.13%
<0.001 <0.001
0.04%
0.05%
0.836
0.04%
0.10%
0.409
0.09%
0.10%
0.933
71.04% 67744.56 § 58320.36 13.74 § 11.42
76.67% 50084 § 37946.44
<0.001 <0.001
9.87 § 8.26
<0.001 <0.001
38.77% 52.22% 8.70%
47.45% 49.55% 2.82%
<0.001
0.390
Postoperative complications are commonly seen in patients with cirrhosis who underwent cardiac surgery.17 Previous studies have documented complication rates ranging from 28% to 69%.4,16,18,19 Common complications include bleeding, respiratory failure, infection, and deep venous thrombosis. Postoperative complications were common in our study, including hemorrhage requiring transfusion, respiratory failure, acute renal failure requiring dialysis, infections, and pressure ulcers. Predictors of postoperative complications included cirrhosis, ascites, Charlson score ≥ 2, use of intra-aortic balloon pump, cardiogenic shock, and concomitant valve surgery. In-hospital mortality remains high for patients with cirrhosis who underwent CABG ranging from 7% to 17% in previous studies.4,16−19 Previously described predictors of mortality include EuroSCORE, advanced age, central venous pressure, thrombocytopenia, total bilirubin, CPB time, and total operative time.17 In our study, in-hospital mortality remained elevated but decreased significantly in recent years. Predictors of in-hospital mortality included presence of postoperative complications, ST-elevation myocardial infarction, cirrhosis, ascites, age, female gender, black gender, use of intra-aortic balloon pump, cardiogenic shock, and concomitant valve surgery. Meanwhile, CPB had a protective effect. Current liver disease prediction models like the ChildTurcotte-Pugh classification and the Model for End-stage Liver Disease score have been previously used to predict
Table 3 Complications in patients with cirrhosis who underwent coronary artery bypass grafting in the United States 2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
P trend
2,231 987 16.00% 14.52%
173 65 9.25% 8.09%
191 74 7.85% 6.81%
169 54 12.43% 11.24%
149 63 8.72% 7.38%
185 71 10.27% 9.19%
145 62 12.41% 10.34%
157 68 11.46% 9.55%
204 89 13.73% 12.25%
148 67 18.92% 15.54%
155 88 30.32% 28.39%
160 81 24.38% 23.13%
199 97 24.62% 24.12%
196 108 23.47% 21.94%
<0.001 <0.001 <0.001
2.06%
1.16%
1.05%
1.78%
2.01%
2.16%
2.76%
3.18%
1.47%
4.05%
1.94%
3.13%
1.01%
2.04%
0.436
14.75% 0.49%
19.65% 0%
16.23% 0%
12.43% 0%
14.09% 0%
11.35% 0%
14.48% 0%
11.46% 0%
12.75% 0%
10.81% 0%
15.48% 0%
14.38% 2.50%
15.08% 1.51%
21.94% 2.04%
0.537 <0.001
10.09%
17.34%
12.04%
8.28%
10.74%
6.49%
9.66%
7.64%
7.35%
7.43%
11.61%
8.13%
9.55%
14.29%
0.402
1.34% 2.02% 0.58%
2.31% 0.58% 0.00%
2.09% 1.57% 0.52%
1.78% 1.18% 0.59%
0.67% 1.34% 0%
1.62% 2.16% 0%
1.38% 2.07% 0%
0% 1.27% 1.27%
2.94% 2.94% 0.98%
0.68% 2.03% 0%
0% 1.94% 0.65%
0.63% 1.25% 1.88%
1.51% 2.01% 0.50%
1.02% 5.10% 1.02%
0.150 0.018 0.079
1.70%
2.89%
3.14%
1.78%
0.67%
2.70%
2.76%
0.64%
1.47%
1.35%
1.94%
0.63%
1.51%
0.51%
0.031
0.81% 12.73% 1.79% 13.00% 2.20%
0.58% 13.87% 2.31% 9.83% 4.05%
0.52% 19.37% 2.62% 13.09% 6.81%
0.59% 8.88% 1.18% 8.28% 2.37%
2.01% 10.07% 2.01% 9.40% 0.67%
0.54% 12.43% 2.16% 7.03% 6.49%
0.69% 15.17% 0.69% 12.41% 5.52%
1.91% 14.01% 3.82% 12.74% 2.55%
0.49% 8.33% 1.47% 11.27% 0%
0.68% 7.43% 1.35% 10.14% 0%
0.65% 12.26% 2.58% 14.19% 0%
0% 16.25% 0% 25.00% 0%
0.50% 13.07% 1.01% 19.10% 0%
1.53% 13.78% 2.04% 15.82% 0%
0.959 0.637 0.305 <0.001 <0.001
1.97%
0.58%
2.62%
1.78%
3.36%
1.62%
2.07%
1.91%
2.45%
2.70%
1.29%
1.25%
2.51%
1.53%
0.996
2.38% 2.06%
0.58% 0.58%
2.09% 1.57%
1.78% 1.78%
2.68% 2.01%
1.62% 1.62%
3.45% 3.45%
5.10% 4.46%
1.47% 1.47%
2.03% 1.35%
0.65% 0.65%
1.88% 1.88%
2.51% 2.51%
5.10% 3.57%
0.106 0.199
0.31%
0.00%
0.52%
0%
0.67%
0%
0%
0.64%
0%
0.68%
0%
0%
0%
1.53%
0.254
1.39%
2.89%
0.52%
2.37%
0%
1.08%
1.38%
0.64%
1.47%
1.35%
0%
2.50%
2.01%
1.53%
0.925
6.28% 8.43%
7.51% 0.58%
4.71% 2.62%
5.92% 3.55%
4.70% 10.07%
6.49% 8.11%
4.83% 8.28%
5.10% 12.10%
8.82% 10.29%
5.41% 14.86%
7.74% 10.32%
5.63% 14.38%
8.04% 7.54%
5.61% 9.18%
0.525 <0.001
ARTICLE IN PRESS
2002
Coronary Artery Disease/CABG in Cirrhosis
Total cases with cirrhosis Complications (number of cases) Vascular complications Hemorrhage requiring transfusion Other vascular complications including Cardiac complications Post-operative cardiogenic shock Iatrogenic cardiac complications Complete heart block Other heart block Temporary pacemaker placement Permanent pacemaker placement Pericardial complications Respiratory complications Iatrogenic pneumothorax Respiratory failure Other iatrogenic respiratory complications Neurological complications (stroke or transient ischemic attack) Renal and metabolic complications Acute renal failure requiring dialysis Acute severe metabolic derangement Deep vein thrombosis or pulmonary embolism Infectious complications Pressure ulcers
Overall
7
ARTICLE IN PRESS 8
The American Journal of Cardiology (www.ajconline.org)
Table 4 Propensity-score matching in a 1:2 ratio
Actual cases (number) Mortality Overall complications rate Vascular complications Hemorrhage requiring transfusion Other vascular complications including Cardiac complications Iatrogenic cardiac complications Complete heart block Other heart block Temporary pacemaker placement Permanent pacemaker placement Pericardial complications Respiratory complications Iatrogenic pneumothorax Respiratory failure Other iatrogenic respiratory complications Neurological complications Deep vein thrombosis or pulmonary embolism Infectious complications Pressure ulcers
Cirrhosis
No Cirrhosis
P value
1,084 7.21% 43.91% 16.13% 14.62% 2.12%
2,168 4.07 38.93% 12.33% 10.55% 2.14%
<0.001 0.006 <0.001 <0.001 0.947
15.59% 9.32% 1.48% 2.31% 0.55% 1.69% 0.83% 11.72% 1.94% 11.9% 1.81%
13.93% 10.01% 1.52% 2.58% 0.74% 1.6% 1.06% 9.32% 1.75% 9.27% 2.03%
0.212 0.306 0.919 0.633 0.545 0.758 0.53 0.032 0.71 0.019 0.721
1.94% 0.92%
1.71% 1.38%
0.639 0.261
6.09% 9.78%
4.89% 2.12%
0.15 <0.001
outcomes in patients with liver disease who underwent cardiac surgery.2,3,20,21 Child-Turcotte-Pugh scores >7 (class B or C) and Model for End-stage Liver Disease scores >13 have been suggested as "thresholds" beyond which mortality increased significantly. The optimal revascularization strategy for patients with advanced liver disease remains unknown. The use of off-pump CABG has yielded conflicting results. Full percutaneous revascularization has also been proposed as an alternative.19,22,23 Bare metal stents have been frequently used in patients with cirrhosis to avoid the need for prolonged use of dual antiplatelets. However, a recent study demonstrated that the use of bare metal stents (as opposed to drug-eluting stents) in patients with advanced liver disease does not decrease bleeding rates in the short term and is associated with increased in-hospital mortality.24 Ultimately, adequate patient selection and preoperative risk stratification with the combined use of conventional cardiac risk scores and liver disease models may lead to reduced improved outcomes. The large case volume, inclusive nature, and heterogeneity of our data are important strengths that offer an insight into the outcomes of patients with cirrhosis who underwent CABG in a “real-world” scenario. Nevertheless, some limitations are worth noting: (1) absence of certain patient characteristics including laboratory findings hinder calculation of liver prediction models and thus diagnosis of cirrhosis relies on coding (with the possibility for miscoding); (2) some procedural characteristics are not reported (i.e., CPB times) precluding further analysis of the impact of these variables; and lastly (3) selection bias may be present as patients who were managed medically or with PCI are not included in our analysis.
In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States. Postoperative complications are common, and in-hospital mortality remains high but has decreased in recent years. The presence of cirrhosis should be taken into consideration along with traditional cardiac risk assessment models before selecting the ideal approach to revascularization. Disclosures The authors have no conflicts of interest to disclose. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.amj card.2018.08.026.
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