title: Aortic Valve Replacement in Patients with End-Stage Liver Disease: A Modified Perfusion Concept in High-Risk Patients.
abstract: OBJECTIVE
  Cardiac surgery with the use of cardiopulmonary bypass in patients with end-stage liver disease is associated with a high risk of postoperative morbidity and mortality due to bleeding, and a high incidence of bacterial infection with associated secondary complications. Minimized extracorporeal perfusion circuits (MECCs) with a lower priming volume, reduced foreign surface area, and interdisciplinary preoperative and postoperative treatment may address these negative effects and improve patient outcomes. The study aim was to evaluate the feasibility of the MECC and optimized supportive therapy in patients with advanced-stage liver cirrhosis.
  
  
  METHODS
  Seven consecutive male patients (median age 56 years; range 54-67 years) with hepatic cirrhosis (Child-Pugh score B, median Model of End-stage Liver Disease (MELD) score 14; range 8-26) underwent aortic valve replacement (AVR) using MECC. Supportive preoperative and postoperative management included digestive decontamination, antioxidant supplements, and adjusted anti-infective therapy.
  
  
  RESULTS
  All patients survived the hospital course, with 30-, 60-, and 90-day mortality of 0%. The median intensive care unit and in-hospital lengths of stay were 3 days (range: 1-5 days) and 13 days (range: 5-18 days), respectively. One patient required reexploration due to bleeding, and another suffered from a seizure without permanent neurologic deficits. No patient required new-onset hemodialysis. At a median follow up of 22 months (range: 2-46 months) all patients were alive but displayed only minor improvements in cardiac symptoms (median NYHA class III (range: II-III) at baseline versus II (range: II-III) postoperatively) and hepatic symptoms.
  
  
  CONCLUSIONS
  Conventional AVR in patients with advanced-stage liver cirrhosis using MECC and optimal medical treatment is feasible. Further studies are required to evaluate the impact of alternative interventional techniques in this high-risk cohort.
authors.forename: Sven
authors.initials: S
authors.lastname: Peterss
authors.forename: Erik
authors.initials: E
authors.lastname: Beckmann
authors.forename: Rohan
authors.initials: R
authors.lastname: Bhandari
authors.forename: Johannes
authors.initials: J
authors.lastname: Hadem
authors.forename: Christian
authors.initials: C
authors.lastname: Hagl
authors.forename: Nawid
authors.initials: N
authors.lastname: Khaladj
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
authors.forename: Ingo
authors.initials: I
authors.lastname: Kutschka
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000601:surgery; D005112:Extracorporeal Circulation / Q000379:methods*; D005240:Feasibility Studies; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007902:Length of Stay; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011788:Quality of Life; D012189:Retrospective Studies