|Year : 2016 | Volume
| Issue : 2 | Page : 56-60
Evaluation of early postoperative complications after open heart surgery in Hepatitis-B positive patients
Dheeraj Sharma1, Anula Sisodia2, Sanjeev Devgarha2, Rajendra Mohan Mathur2
1 Department of Cardiac Surgery, Rajiv Gandhi Superspeciality Hospital , New Delhi, India
2 Department of Cardiothoracic and Vascular Surgery, S.M.S Medical College, Jaipur, India
|Date of Web Publication||6-Jun-2016|
House No. 530, Lane No. 5, Raja Park, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Postoperative course of cardiac surgery patients in presence of liver dysfunction is associated with a lot of complications like excessive bleeding, coagulopathy, hepatic decompensation, multiple organ failure, infections which account for increased mortality and morbidity among this subset of patients. Method: In this study we evaluate early postoperative outcome of elective cardiac surgery in patients with hepatitis B infection. We studied 21 patients with hepatitis B infection who underwent open heart surgery done at department of cardiothoracic surgery, S.M.S Medical college, Jaipur, Rajasthan, India. All preoperative, operative and postoperative data was collected and analysed. Results: Out of 21 patient 13 were operated for coronary artery bypass grafting of these 7 were done offpump and 6 were done onpump. Out of remaining 8 patients 5 were mitral valve replacement for mitral valve disease and 3 were double valve replacement. Out of 21 patients 9 were re-explored for bleeding. Of the total patients operated 5 patients died, of which 1 succumb to renal failure, 3 died due to excessive bleeding and coagulopathy and 1 died due to delayed recovery following cerebral haemorrhage. 6 patients developed sternal wound infection and 2 out of these required sternal rewiring and debridement. Mean hospital stay was around 18 days with mortality of 23.8% and mobidity of around 28.6%. Conclusion: In the study group we found that there is considerable increase in mortality and morbidity among patients with hepatitis B infection that underwent open heart surgery.
Keywords: Coagulopathy, debridement, hepatic decompensation, multiple organ failures
|How to cite this article:|
Sharma D, Sisodia A, Devgarha S, Mathur RM. Evaluation of early postoperative complications after open heart surgery in Hepatitis-B positive patients. Heart India 2016;4:56-60
|How to cite this URL:|
Sharma D, Sisodia A, Devgarha S, Mathur RM. Evaluation of early postoperative complications after open heart surgery in Hepatitis-B positive patients. Heart India [serial online] 2016 [cited 2020 Jul 7];4:56-60. Available from: http://www.heartindia.net/text.asp?2016/4/2/56/183521
| Introduction|| |
Patients with moderate to severe hepatic dysfunction undergoing cardiac surgery have a high mortality. There is a paucity of data regarding the effects of cardiac surgery either with or without cardiopulmonary bypass (CPB) on patients with hepatic dysfunction. Indeed, the use of CPB with moderate to severe hepatic dysfunction is associated with increased postoperative bleeding, infections, renal failure, respiratory failure, and hepatic decompensation. The aim of this study is to show the presence of high postoperative complications after open heart surgery in patients with hepatic dysfunction.
| Materials and methods|| |
In this study, we evaluated the early postoperative outcome of elective cardiac surgery in patients with asymptomatic hepatitis-B infection. We studied 21 patients with asymptomatic hepatitis-B infection who underwent open heart surgery at the Department of Cardiothoracic and Vascular Surgery at S.M.S Medical College and Hospital, Jaipur, Rajasthan, India from June 2011 to September 2013. All preoperative, operative, and postoperative data were collected and analyzed. The exclusion criteria include:
- Presence of other comorbidities
- Patients with history of previous cardiac surgery
- Patients with symptomatic liver dysfunction (Child-Pugh Class B and C)
- Patients with other concomitant viral infections affecting the hepatobiliary system.
All the patients did not have any complaint regarding liver dysfunction in the preoperative period. In the ultrasonological examination of abdomen, 11 out of 21 patients had mild hepatomegaly. There was no evidence of jaundice presently and also in the past medical history. There was no history of bleeding diathesis. According to Child-Pugh classification, of 21 patients, 14 were in Child-Pugh Class B and remaining seven were in Class A.
All the patients were operated after informed consent about the risk of suspected increased mortality and morbidity. Of 21 patients, coronary artery bypass was done in 13 cases (seven cases off-pump and six on-pump) in remaining eight cases, five were mitral valve replacements and three were double valve replacements [Table 1].
The mean chest tube drainage in first 24 h was about 930 ml, and minimal drainage was about 430 ml, and maximum drainage is around 3800 ml. Of 21 patients, nine were re-explored for bleeding and all these patients had raised prothrombin time and liver enzymes level in the preoperative period which might have contributed to the coagulopathy. There was a significant difference in drainage in off-pump and on-pump bypass grafting; mean drainage is significantly more in the on-pump group [Table 2] that too involving patients with altered biochemistry. Drainage was maximum in double valve replacement category. There appears to be a strong correlation between duration of ventilatory support required before extubation and use of CPB in surgery, this group requires more duration of ventilatory support as compared to their counterparts which are done off-pump [Table 3]. The most probable reason for this appears to be immune-mediated lung injury and accumulation of excess fluid in the interstitial space leading to reduced compliance of lung.
Postoperative sternal wound infection is more common in cases in which patient was taken on CPB. Five out of six patients who developed sternal wound infection were done on CPB and two out of these five required sternal rewiring and debridement, before developing frank mediastinitis these patients were the same who drained excessively during the immediate postoperative period and had raised liver enzymes as well as prothrombin time in the preoperative period [Table 4]. Nearly, all these patients had wound discharge at about 3 rd postoperative day which was due to collected and hemolyzed blood in between sternum and skin.
Intensive Care Unit stay, as well as hospital stay, is significantly more in cases done on bypass [Table 5]. Most probably related to the reoperations, increased bleeding, altered renal function tests, and reduced pulmonary functions in the postoperative period following CPB.
The mortality rate is also significantly higher among patients operated on CPB; mortality rate is 0% in off-pump coronary bypass surgery as compared to 36% in cases where CPB was used [Table 6]. Of five patients, three died due to excessive bleeding (60%), one developed renal failure and died (20%), and one patient died due to mediastinitis and septicemia (20%) and four out these five patients were having raised liver enzymes and altered renal functions and raised prothrombin time and only a single patient had expired who had normal laboratory parameters in preoperative period that to was due to mediastinitis. All four patients were in Child-Pugh Class B.
|Table 6: Mortality rate: In terms of Child-Pugh class and according to different surgeries|
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| Results|| |
In our study, we analyzed 21 cases of asymptomatic hepatitis-B infection that underwent open heart surgery. Of these 21 patients, 14 were in Child-Pugh Class B and seven were in Class A. Of 21 patients, 13 were operated for coronary artery bypass grafting (CABG) of these seven were done off-pump and six were done on-pump. Of remaining eight patients, five were mitral valve replacement for mitral valve disease and three were double valve replacement. The mean chest tube drainage in first 24 h was about 930 ml (as compared to 350 ml in normal cases), minimal drainage was about 430 ml (as compared to 130 ml in normal cases), and maximum drainage is around 3800 ml (as compared to 1100 ml in the normal case). Of 21 patients, nine (42.8%) were re-explored for bleeding (re-exploration rate for normal patients after open heart surgery in our setup is around 8%). The mean ventilation time was around 11.3 h (in normal cases the mean ventilation period is around 6.9 h). Mean Intensive Care Unit stay was around 5-7 days (as compared to 3 days for normal patients). Of the total patients operated, five patients died, of which one succumb to renal failure, three died due to excessive bleeding and coagulopathy, and one died due to delayed recovery following cerebral hemorrhage (overall mortality for open heart surgery in our setup is around 3% for coronary bypass surgery and 3-5% for valvular heart surgery). Six patients developed sterna wound infection and two out of these required sternal rewiring and debridement. Mean hospital stay was around 18 days (as compared to 7 days for normal patients) with mortality of 23.8% and morbidity of around 28.6%. In terms of Child-Pugh class, Class A has one mortality out of seven patients (14%) which too is due to sterna wound infection. Remaining mortalities were in Class B (4 out of 14 which come out to be 28.57%). These data are in accordance to various data available. Moreover, the infection rate is considerably higher in Child-Pugh Class B (35.71%) as compared to 14.28% in Child-Pugh Class A.
| Discussion|| |
Morbidity and mortality rates after cardiac operation with CPB in patients with hepatic dysfunction are high. Major morbidity has been reported to be 10-100%, 66-100%, and 100% for Child-Pugh Class A, B, and C, respectively, mostly attributable to cirrhotic complications rather than impaired cardiac function. Mortality has been reported to average 3% (2 out of 75 patients), 45% (15 out of 33 patients), and 66% (two out of three patients) for Child-Pugh Class A, B, and C, respectively. ,,,,,,,, Major perioperative complications include infections (mainly mediastinitis, sternal wound infection, and sepsis), renal failure, bleeding (gastrointestinal bleeding, cardiac tamponade, and mediastinal bleeding as suggested by increased hemorrhagic chest tube output), fluid retention (including ascites, pleural, and pericardial effusion), and hepatic decompensation. Pathophysiologic basis of above-mentioned changes due to hepatic dysfunction has been recently outlined.  These patients have decreased reticuloendothelial function and impaired immune function. This, in addition to poor nutritional status, increases their susceptibility to infections which are much more prevalent in the hepatic dysfunction patients undergoing operation and are the leading cause of death in this patient population. Hepatic dysfunction is also associated with coagulopathy that results from decreased synthesis of coagulation factors, splenic sequestration of platelets with thrombocytopenia, and fibrinolysis because of low concentration of antiplasmin and inadequate clearance of tissue plasminogen activator. Because of this very high morbidity and mortality, it is generally agreed that elective cardiac operations using CPB are contraindicated in patients with moderate to severe hepatic dysfunction.  The pathogenesis of adverse outcome after the use of CPB is complex and multifactorial and includes nonpulsatile flow, hemodilution, hemolysis, activation of the inflammatory cascade, anticoagulation, hypothermia, and reduced end-organ perfusion.  Consequently, coagulation, vascular permeability, fluid balance, and organ function may be affected. Thus, avoidance of CPB use in cirrhotic patients may theoretically lower the risk of perioperative morbidity. In a recent study, on-pump CABG was associated with more chest drainage, blood and blood products transfusion, and longer duration of dopamine infusion compared with off-pump coronary artery bypass (OPCAB) surgery.  This is in accordance with our study. Current best available evidence from randomized control trials suggests that OPCAB reduces bleeding and need of allogeneic transfusion.  Only nine cases of cirrhotic patients undergoing OPCAB surgery, all of whom were suffering Child-Pugh A and B cirrhosis, have been previously described. The data from these reports suggest that OPCAB surgery may be associated with lower morbidity and mortality compared with on-pump surgery. ,,,, In Child-Pugh Class A and B patients, the reported morbidity was 0% (0 out of five patients) and 25% (one out of four patients), respectively, and none of the patients died.
Klemperer et al. 1998 identified 13 patients (eight Child-Pugh Class A, five Child-Pugh Class B) in a retrospective study with a preoperative history of cirrhosis. All patients underwent CPB for a variety of cardiac procedures. Significant postoperative complications occurred in 25% of Child-Pugh Class A patients and in 100% of Child-Pugh Class B patients. The causes of death were due mainly to major infection or hemorrhagic complications and not cardiac performance per se.  In a series of ten patients, Kaplan et al. reported similar findings with Child-Pugh Class B having a 50% mortality (three of six patients) and no deaths with four Class A patients. The causes of death were again not directly related to cardiac failure but rather hepatorenal syndrome, hemorrhage, or sepsis.  Bizouarn et al. reported on early and late outcomes 12 cirrhotic patients (ten Class A, two Class B). In the immediate postoperative period, 50% of Class A and 100% of Class B patients developed significant complications. There was one death with Class B patients and two deaths with Class A; however, the two Class A patients died during the follow-up period after discharge from the hospital. 
More recently, Hayashida reported on 18 patients (ten Child-Pugh Class A, seven Class B, and one in Class C) undergoing cardiac operations. Fifteen of 18 patients had surgery with CPB, while three patients had off-pump CABG. All patients in Class B and C had major complications including bleeding, infection, renal failure, or respiratory failure. Sixty percent of Class A patients had such outcomes. There were no deaths in Class A and 50% mortality in Class B patients that utilized CPB. All three patients in Class B that underwent bypass grafting without the use of CPB survived.  Off-pump CABG in moderate to severe cirrhosis may be advantageous as it avoids many of the complications associated with CPB such as poor coagulation profile, decreased vascular tone, massive fluid shifts, and whole body inflammatory response.  Suman have published by far the largest study to date with 44 total patients (31 Class A, 12 Class B, and 1 Class C).  They report that Child-Pugh score and MELD score are significantly associated with hepatic decompensation and mortality. Furthermore, they determined a cut-off Child-Pugh score of >7 had a sensitivity and specificity of 86% and 92% for mortality, with a negative predictive value of 97% and a positive predictive value of 67%, respectively. Hepatic decompensation is defined by Suman as the appearance of new ascites, portosystemic encephalopathy, jaundice, coagulopathy, variceal bleed, or hepatorenal syndrome within 3 months following cardiac surgery. Only about 10% (3 of 31) of Child-Pugh Class A patients developed hepatic decompensation, while 66% (8 of 12) of Child-Pugh Class B and 100% (1 of 1) of Child-Pugh Class C had complications. Mortality in the series was 3% (1 of 31), 41% (5 of 12), and 100% (1 of 1) for Child-Pugh Class A, B, and C, respectively. In their final analysis, Suman suggested that Child-Pugh score >7 is sufficient to predict a negative outcome after cardiac surgery
Our study is first in its type which describes increased mortality and morbidity in asymptomatic hepatitis-B positive patients who underwent open heart surgery. Most of the studies in this field are restricted to symptomatic patients, but our study includes only asymptomatic patients. In accordance with the study of Suman et al., Klemperer et al., and Kaplan et al. which showed mortality up to 50% in Child-Pugh Class B our study also characterizes the same and in our study the mortality in Class B comes out to be 28.57%.
| Conclusion|| |
In the study group, we found that there is a considerable increase in mortality and morbidity among patients with asymptomatic hepatitis-B infection that underwent open heart surgery with increased frequency of postoperative complications, especially bleeding and wound infections. All the above findings are largely in accordance with the data provided by previous studies. Our study also shows that mortality and morbidity are higher in Child-Pugh Class B as compared to Class A, which is in accordance with the previous studies. There are some variations which might be due to the fact that population in the Indian subcontinent is very different from that of Western world in terms of their nutritional status, geographic variations, economical aspect, and most importantly unavailability of quality health care in remote areas of country. All these factors are largely responsible for increased mortality and morbidity in Indian population.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]