Hyperbilirubinaemia after cardiac surgery: the point of no return

Abstract

Aims The occurrence of hyperbilirubinaemia after heart surgery using cardiopulmonary bypass or post‐operative heart failure is fairly common. We investigated the incidence, predictive value, and post‐operative outcome of hyperbilirubinaemia after cardiac surgery in an effort to identify potential risk factors and significance on clinical outcome. Methods and results Between 2006 and 2016, 1272 (10.1%) out of 12 556 patients developed hyperbilirubinaemia, defined as bilirubin concentration >3 mg/dL, during post‐operative course at our institution. All patients who were operated using cardiopulmonary bypass were included. Hepatic dysfunction was diagnosed preoperatively in 200 patients (15.7%), whereas mean model of end‐stage liver disease score was 11.22 ± 4.99. Early mortality was 17.4% with age [hazard ratio (HR) 1.019, 95% confidence interval (CI) 1.008–1.029; P = 0.001], diabetes (HR 1.115, CI 1.020–1.220; P = 0.017), and emergent procedures (HR 1.315, CI 1.012–1.710) as multivariate predictors. Post‐operative predictors were low‐output syndrome (HR 3.193, 95% CI 2.495–4.086; P < 0.001), blood transfusion (HR 1.0, CI 1.0–1.0; P < 0.001), and time to peak bilirubin (HR 1.1, CI 1.0–1.1; P < 0.001). We found an increased correlation with mortality at 3.5 post‐operative day as well as an optimal cut‐off value for bilirubin of 5.35 mg/dL. A maximum bilirubin of 25.5 mg/dL was associated with 99% mortality. Survival analysis showed significantly decreased survival for patients who developed late, rather than early, hyperbilirubinaemia. Conclusions Post‐operative hyperbilirubinaemia is a prevalent threat after cardiopulmonary bypass, associated with high early mortality. The timing and amount of peak bilirubin concentration are linked to the underlying pathology and are predictors of post‐operative outcome. Patients with late development of steep hyperbilirubinaemia warrant meticulous post‐operative care optimizing cardiac and end organ functions before reaching the point of no return.

Characteristics and outcomes of Stanford type A aortic dissection patients with post-operation severe hyperbilirubinemia: a retrospective cohort study

“…Aging indicated diminished functional capacity of the liver and added to the cumulative burden in the case of developed hyperbilirubinemia. Additionally, different from the a recent study outlining the increased risk of mortality for patients with hyperbilirubinemia after cardiac surgery associated with time to peak bilirubin, [29] our study indicated that peak TB concentration was an independent driver of in-hospital mortality for patients with severe hyperbilirubinemia after AAD surgery. And, we found out that the optimal cut-off value of peak TB on predicting in-hospital mortality was 121.2 µmol/l.…”

“…In previous studies, older age had been identified as an independent risk factor of mortality for patients with hyperbilirubinemia after cardiac surgery. [29] In our present study, older age was established a risk factor for in-hospital mortality for patients with hyperbilirubinemia after AAD surgery as well. Aging indicated diminished functional capacity of the liver and added to the cumulative burden in the case of developed hyperbilirubinemia.…”

“…It has been reported that severe hyperbilirubinemia was associated with increased mortality in patients underwent cardiac surgery. [10,15,17] Up to now, limited information was available on the risk factors associated with in-hospital and long-term mortality in AAD patients with post-operation severe hyperbilirubinemia. Our presented study had several findings.…”

“…[9][10][11][12][13][14] For patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), recent studies suggested that severe hyperbilirubinemia (5 times the normal upper limit) instead of mild bilirubin significantly increased patient mortality. [15] Additionally, the occurrence of acute kidney injury (AKI) and the acceptance of continuous renal replacement therapy (CRRT) after cardiac surgery were suggested to be associated with the decrease of patient survival proportion. As we know, the pathogenesis, disease severity classification, prognosis, and operation method are different between different cardiac diseases.…”

Characteristics and outcomes of Stanford type A aortic dissection patients with severe post-operation hyperbilirubinemia: a retrospective cohort study

“…[6,7,[11][12][13] For patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), recent study suggested that severe hyperbilirubinemia (5 times the normal upper limit) instead of mild bilirubin signi cantly increased patient mortality and a maximum bilirubin of 25.5 mg/dl was associated with 99% mortality. [14] Mild or moderate hyperbilirubinemia might be associated with hemolysis, cardiotomy suction, gaseous micro-emboli, and blood transfusions during CPB, which were temporary and revisable. However, severe hyperbilirubinemia could induce oxidative stress and cell apoptosis, which cause respiratory failure, thrombocytopenia, and even neurological dysfunction, and consequently promote multiple organ dysfunction syndrome (MODS) and increase patient in-hospital mortality.…”