Patients with end-stage liver disease frequently require invasive cardiac procedures in preparation for liver transplantation. Because of the impaired hepatic function, these patients often have a prolonged prothrombin time and elevated international normalized ratio (INR). To determine whether an abnormal prothrombin time/INR is predictive of bleeding complications from invasive cardiac procedures, we retrospectively reviewed, for bleeding complications, the databases and case records of our series of patients with advanced cirrhosis who underwent cardiac catheterization. A total of 157 patients underwent isolated right-sided heart catheterization, and 83 underwent left-sided heart catheterization or combined left- and right-sided heart catheterization. The INR ranged from 0.93 to 2.35. No major procedure-related complications occurred. Several patients in each group required a blood transfusion for gastrointestinal bleeding but not for procedure-related bleeding. No significant change was found in the hemoglobin after right-sided or left-sided heart catheterization, and no correlation was found between the preprocedure INR and the change in postprocedure hemoglobin. When comparing patients with a normal (≤1.5) and elevated (>1.5) INR, no significant difference in hemoglobin after the procedure was found in either group. In conclusion, despite an elevated INR, patients with end-stage liver disease can safely undergo invasive cardiac procedures. An elevated INR does not predict catheterization-related bleeding complications in this patient population.
At present, few published data are available regarding the bleeding risk from cardiac procedures in patients with end-stage liver disease (ESLD). Three single-center studies have been published comparing patients with ESLD to matched cohorts and have found a similar to slightly greater procedure-related complication rate in those with ESLD. Of particular interest were the findings that the preprocedure international normalized ratio (INR) was associated with bleeding risk and, in a second study, that the treatment of an INR >1.6 with fresh frozen plasma (FFP) might have a reduced bleeding risk. Therefore, we sought to determine whether an elevated INR is predictive of complications from cardiac catheterization in patients with ESLD.
Methods
After approval by the Medical University of South Carolina institutional review board, we searched our liver transplant and heart catheterization databases for patients undergoing invasive cardiac procedures from May 2003 to August 2009. The patients were divided into those undergoing isolated right-sided heart catheterization (RHC) or left-sided heart catheterization (LHC); the latter group included those undergoing LHC with or without associated RHC.
We collected the demographic, laboratory, and procedural data for each patient. The model for end-stage liver disease scores and body mass index were calculated for each patient.
Venous access in the isolated RHC group was predominately in an internal jugular vein (90 of 157, 57%) with the remainder femoral. A 7F sheath was used most often (139 of 157, 89%). Most patients with combined RHC and LHC had femoral venous access (58 of 66, 89%) with a 7F sheath (65 of 66, 98%). Arterial access was uniformly in a femoral artery, with 4F (40 of 83, 48%) and 6F (34 of 83, 41%) sheaths used most commonly. Neither ultrasound guidance nor micropuncture technique was routinely used during the study period.
The daily notes and radiology reports were searched for any evidence of vascular complications or significant bleeding at the catheterization sites or elsewhere. We specifically searched for the development of arteriovenous fistulas, aneurysms or pseudoaneurysms, evidence of retroperitoneal bleeding, hematomas, or intracranial bleeding. Outpatients with an uncomplicated course were discharged after the procedure, and, as a result, follow-up laboratory data were only available for 62% of the isolated RHC and 70% of the LHC group.
The administration of platelets and FFP within 24 hours of the procedure was also recorded, as well as red blood cell infusion at any point afterward. The decision to transfuse FFP or platelets was at the discretion of the cardiologist performing the procedure.
Statistical analysis was performed with Spearman’s rank correlation coefficient to search for a relationship between INR and postprocedural hemoglobin changes. Postprocedural differences in hemoglobin were also compared between subgroups with a normal (≤1.5) and elevated (>1.5) INR, using Student’s t test. A p value <0.05 was considered statistically significant.
Results
A total of 157 patients had undergone isolated RHC and 83 had undergone LHC, of whom a large majority (66 of 83) had undergone associated RHC. The mean INR in the patients undergoing isolated RHC was 1.5 ± 0.3 (range 0.93 to 2.35). In the LHC group, the mean INR was 1.38 ± 0.3 (range 0.94 to 2.15). The demographic, laboratory, and procedural data are listed in Table 1 .
| Variable | RHC (n = 157) | p Value | LHC (n = 83) | p Value | ||
|---|---|---|---|---|---|---|
| INR ≤1.5 61% | INR >1.5 39% | INR ≤1.5 72% | INR >1.5 28% | |||
| Age (years) | 55 ± 7.9 | 52 ± 10 | 0.07 | 57 ± 9.2 | 52 ± 7.8 | 0.02 |
| Men | 57% | 62% | 0.84 | 73% | 61% | 0.78 |
| White | 79% | 89% | 0.65 | 78% | 91% | 0.81 |
| Weight (kg) | 90 ± 22 | 89 ± 22 | 0.76 | 93 ± 17 | 90 ± 25 | 0.52 |
| Body mass index (kg/m 2 ) | 31 ± 7 | 29 ± 6 | 0.24 | 31 ± 5 | 30 ± 7.3 | 0.62 |
| Systolic blood pressure (mm Hg) | 125 ± 21 | 121 ± 18 | 0.24 | 122 ± 23 | 121 ± 21 | 0.91 |
| Diastolic blood pressure (mm Hg | 72 ± 12 | 67 ± 13 | 0.01 | 65 ± 13 | 64 ± 14 | 0.76 |
| Hemoglobin (g/dl) | 12 ± 2.0 | 10 ± 2.1 | <0.01 | 12 ± 2.1 | 10 ± 1.9 | <0.01 |
| Platelets (ml) | 101 ± 57 | 105 ± 102 | 0.79 | 97 ± 53 | 77 ± 32 | 0.1 |
| Creatinine (mg/dl) | 1.35 ± 1.0 | 1.57 ± 1.7 | 0.31 | 1.49 ± 1.2 | 1.58 ± 1.2 | 0.76 |
| Model for end-stage liver disease | 13 ± 5.3 | 21 ± 7.4 | <0.01 | 14 ± 6.4 | 22 ± 6.4 | <0.01 |
| International normalized ratio | 1.3 ± 0.14 | 1.8 ± 0.21 | <0.01 | 1.25 ± 0.14 | 1.74 ± 0.18 | <0.01 |
| Concurrent right-sided heart catheterization | 75% (45) | 91% (21) | 0.12 | |||
No major vascular complications or procedure-related bleeding events were identified in any patient. Of those with complete laboratory data, no significant difference was seen between the pre- and postprocedure hemoglobin in the isolated RHC (10.5 vs 10.5 g/dl, p = 0.83) or LHC (11.1 vs 11 g/dl, p = 0.83) group. In patients with isolated RHC, no significant change was seen in hemoglobin in either the normal or elevated INR groups (9.7 vs 9.7 g/dl, p = 0.98, and 11.1 vs 10.9 g/dl, p = 0.1, respectively). Similarly, in the LHC group, no significant change in hemoglobin was found in the normal or elevated INR group (9.5 vs 9.6 g/dl, p = 0.87, and 9.7 vs 9.7 g/dl, p = 0.99, respectively; Figure 1 ). To search for a relationship between the postprocedure changes in hemoglobin and INR, the corresponding values were plotted, but no correlation was seen in either the RHC (ρ = 0.1176; p = 0.248) or LHC (ρ = −0.0463; p = 0.820) group ( Figure 2 ).
