Patients with cirrhosis who require open heart surgical procedures are among the most challenging and complex patients seen in cardiac surgery. Liver disease results in physiologic derangements that are only exacerbated by surgery and cardio pulmonary bypass. In this issue of Liver Transplantation, Filsoufi et al. 1 from Mt. Sinai Medical Center in New York report their experience with 27 patients with cirrhosis who required cardiac surgical procedures. The overall morbidity and mortality was high, which was directly associated with the severity of Child-Pugh classification. Interestingly, as opposed to others, the Model for End-Stage Liver Disease score was not predictive of outcomes. 2 This study raises several questions: First, in the elective setting, should cardiac surgery be offered to patients with advanced liver cirrhosis? Second, are there other alternatives that could be considered rather than operating on patients with advanced cirrhosis? The challenge to answering the first question relates to the difficulty that we as surgeons have in turning down patients who do not have any alternatives. This altruistic attitude encourages us to accept these patients in hopes of improving their survival or quality of life. However, caution needs to be exercised when taking on patients with cirrhosis: data provided by Filsoufi et al. suggest that most patients classified as either Childs-Pugh B or C do not gain a survival advantage by surgical correction of their cardiac pathology. Filsoufi et al. report that the expected survival for Child-Pugh class B patients with cirrhosis is 50% at 8 months. More importantly, the survival when considering patients with Child-Pugh class C is merely 50% at 4 months. These data are particularly important to take into account and explained to patients with cirrhosis at the time of consenting for surgery so that an informed decision is made without raising any false hopes or expectations.
An answer to the second question is equally as chal-
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