Outcomes After Minimally Invasive Aortic Valve Replacement In Patients With Liver Disease
Matthew R. Schill, Matthew C. Henn, Richard B. Schuessler, Hersh S. Maniar, Marc R. Moon, Ralph J. Damiano, Jr..
Washington University in St. Louis, Saint Louis, MO, USA.
OBJECTIVE: Patients with liver disease are at increased risk of mortality after cardiac operations. The objective of this study was to examine risk in patients undergoing isolated aortic valve replacement (AVR) with liver disease and to determine if operative approach (full sternotomy [SAVR] vs. ministernotomy [miniAVR] vs. transcatheter [TAVR]) is related to mortality and complications.
METHODS: Between July 2011 and May 2016, 935 patients underwent AVR at a single institution. Of those, 40 had liver disease as defined by Society of Thoracic Surgeons criteria: cirrhosis, viral hepatitis, alcohol dependence, portal hypertension or congestion. Data were obtained from an institutional database and medical records. Baseline characteristics and outcomes were compared.
RESULTS: Patients with liver disease had higher operative mortality compared with those without, but this was not statistically significant (3/40, 8% vs. 25/895, 3%, p=0.11). Among patients with liver disease, those undergoing TAVR were older and had higher rates of diabetes and peripheral vascular disease. Those undergoing SAVR were more likely to be urgent and had higher rates of infective endocarditis. TAVR and miniAVR were associated with shorter intensive care unit (ICU) time and a lower rate of prolonged ventilation compared with SAVR. There was no statistical difference in operative mortality associated with approach (miniAVR 0/5, 0%, vs. SAVR 3/18, 17%, vs. TAVR 0/17, 0%, p=0.3). One- and two-year survival among patients undergoing miniAVR, SAVR and TAVR was 75%, 83% and 81%, and 75%, 75% and 49% respectively (Figure). Four patients had Model for End-Stage Liver Disease (MELD) score ≥20; they had 50% operative mortality; both surviving patients were alive at two years.
CONCLUSIONS: Patients with liver disease and aortic valve disease had acceptable operative mortality after AVR with minimally invasive or standard approaches, but longer-term outcomes were poor. Mortality was very high among those with severe hepatic dysfunction. A minimally invasive approach was associated with lower incidence of prolonged ventilation and shorter intensive care unit stay.
LEGEND: Survival after AVR in patients with liver disease.
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