Cardiac catheterization in patients with end-stage liver disease: Safety and outcomes

Cardiovascular disease assessment and management in liver transplantation

The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.

Using noninvasive clinical parameters to predict mortality and morbidity after cardiac interventions in patients with cirrhosis: A systematic review

BACKGROUND

Cardiovascular disease commonly affects advanced liver disease patients. They undergo cardiac interventions to improve cardiac outcomes. Cirrhosis increases complication risk, including bleeding, renal and respiratory failure, and further decompensation, including death, posing a clinical dilemma to proceduralists. Predicting outcomes is crucial in managing patients with cirrhosis. Our aim was to systematically review clinical parameters to assess the mortality and complication risk in patients with cirrhosis undergoing cardiac interventions.

METHODS

We searched cirrhosis and cardiovascular intervention terminology in PubMed and Excerpta Medica Database (EMBASE) from inception to January 8, 2023. We included studies reporting clinical scores (e.g. Model for End-stage Liver Disease (MELD), Child-Pugh-Turcotte (CPT), cardiovascular interventions, mortality, and morbidity outcomes). We independently abstracted data from eligible studies and performed qualitative summaries.

RESULTS

Eight studies met the inclusion criteria. Procedures included tricuspid valve surgery, catheterization-related procedures, aortic valve replacement (AVR), pericardiectomy, and left ventricular assist device (LVAD) placement. MELD primarily predicted mortality (n = 4), followed by CPT (n = 2). Mortality is significantly increased for MELD > 15 after tricuspid valve surgery. Albumin, creatinine, and MELD were significantly associated with increased mortality after transcatheter AVR (TAVR), although specific values lacked stratification. CPT was significantly associated with increased mortality after cardiac catheterization or pericardiectomy. In LVAD placement, increasing MELD increased the unadjusted odds for perioperative mortality.

CONCLUSIONS

Our systematic review showed that clinical parameters predict mortality and morbidity risk in patients with cirrhosis undergoing cardiac procedures.

Liver Transplantation: Protocol for Recipient Selection, Evaluation, and Assessment

Liver transplantation (LT) is the definitive therapy for patients with end-stage liver disease, acute liver failure, acute-on-chronic liver failure, hepatocellular carcinoma, and metabolic liver diseases. The acceptance of LT in Asia has been gradually increasing and so is the expertise to perform LT. Preparing a patient with cirrhosis for LT is the most important aspect of a successful LT. The preparation for LT begins with the first index decompensation for a patient with cirrhosis. Patients planned for LT should undergo a thorough screening for infections, and a complete cardiac, pulmonology, and psychosocial evaluation pre-LT. In this review, we discuss the indications and contraindications of LT and the evaluation and assessment of patients with liver disease planned for LT.

Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation

Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.

Trends, outcomes, and management of acute myocardial infarction in patients with chronic viral hepatitis

OBJECTIVES

There is a paucity of data on the management and outcomes of chronic viral hepatitis (CVH) patients [including chronic hepatitis B (CHB) and chronic hepatitis C (CHC)] presenting with acute myocardial infarction (AMI).

METHODS

We utilized the National Inpatient Sample database (2001-2019) and studied the management and outcomes of CVH patients with AMI and stratified them by subtypes of CVH. The adjusted odds ratio (aOR) of adverse outcomes in CVH groups were compared to no-CVH groups using multivariable logistic regression.

RESULTS

Of 18,794,686 AMI admissions, 84,147 (0.45%) had a CVH diagnosis. CVH patients had increased odds of adverse outcomes including in-hospital mortality (aOR 1.40, 95%CI 1.31-1.49, p < 0.05), respiratory failure (1.11, 95%CI 1.04-1.17, p < 0.001), vascular complications (1.09, 95%CI 1.04-1.15, p < 0.001), acute kidney injury (1.36, 95%CI 1.30-1.42, p < 0.001), gastrointestinal bleeding (1.57, 95%CI 1.50-1.68, p < 0.001), cardiogenic shock (1.44, 95%CI 1.04-1.30, p < 0.001), sepsis (1.24, 95%CI 1.17-1.31, p < 0.001), and were less likely to undergo invasive management. On subgroup analysis, CHB had higher odds of adverse outcomes than the CHC group (p < 0.05).

CONCLUSION

CVH patients presenting with AMI are associated with worse clinical outcomes. CHB subgroup had worse outcomes compared to the CHC subgroup.

Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans

Background: The goal of cardiac evaluation of patients awaiting orthotopic liver transplantation (OLT) is to identify the patients at risk for cardiovascular events (CVEs) in the peri- and postoperative periods by opportunistic evaluation of coronary artery calcium (CAC) in non-gated abdominal computed tomographs (CT). Methods: We hypothesized that in patients with OLT, a combination of Lee’s revised cardiac index (RCRI) and CAC scoring would improve diagnostic accuracy and prognostic impact compared to non-invasive cardiac testing. Therefore, we retrospectively evaluated 169 patients and compared prediction of CVEs by both methods. Results: Standard workup identified 22 patients with a high risk for CVEs during the transplant period, leading to coronary interventions. Eighteen patients had a CVE after transplant and a CAC score > 0. The combination of CAC and RCRI ≥ 2 had better negative (NPV) and positive predictive values (PPV) for CVEs (NPV 95.7%, PPV 81.6%) than standard non-invasive stress tests (NPV 92.0%, PPV 54.5%). Conclusion: The cutoff value of CAC > 0 by non-gated CTs combined with RCRI ≥ 2 is highly sensitive for identifying patients at risk for CVEs in the OLT population.

Trends, management and outcomes of acute myocardial infarction in chronic liver disease

AIMS

There are limited data on the management and outcomes of chronic liver disease (CLD) patients presenting with acute myocardial infarction (AMI), particularly according to the subtype of CLD.

METHODS

Using the Nationwide Inpatient Sample (2004-2015), we examined outcomes of AMI patients stratified by severity and sub-types of CLD. Multivariable logistic regression was performed to assess the adjusted odds ratios (aOR) of receipt of invasive management and adverse outcomes in CLD groups compared with no-CLD.

RESULTS

Of 7 024 723 AMI admissions, 54 283 (0.8%) had a CLD diagnosis. CLD patients were less likely to undergo coronary angiography (CA) and percutaneous coronary intervention (PCI) (aOR 0.62, 95%CI 0.60-0.63 and 0.59, 95%CI 0.58-0.60, respectively), and had increased odds of adverse outcomes including major adverse cardiovascular and cerebrovascular events (1.19, 95%CI 1.15-1.23), mortality (1.30, 95%CI 1.25-1.34) and major bleeding (1.74, 95%CI 1.67-1.81). In comparison to the non-severe CLD sub-groups, patients with all forms of severe CLD had the lower utilization of CA and PCI (P < .05). Among severe CLD patients, those with alcohol-related liver disease (ALD) had the lowest utilization of CA and PCI; patients with ALD and other CLD (OCLD) had more adverse outcomes than the viral hepatitis sub-group (P < .05).

CONCLUSIONS

CLD patients presenting with AMI are less likely to receive invasive management and are associated with worse clinical outcomes. Further differences are observed depending on the type as well as severity of CLD, with the worst management and clinical outcomes observed in those with severe ALD and OCLD.

Impact Of Cirrhosis On 90-Day Outcomes After Percutaneous Coronary Intervention (from A Nationwide Database)

Patients with cirrhosis often have concomitant coronary artery disease and require percutaneous coronary intervention (PCI). PCI in cirrhotics can be associated with significant risks due to thrombocytopenia, possible coagulopathies, bleeding, and renal failure. Longer term risks of PCI in cirrhotics have not been well studied. Our study seeks to evaluate the 90-day outcomes of PCI in patients with cirrhosis. Patients receiving PCI were identified from the Nationwide Readmissions Database from 2010 to 2014 and stratified by the presence of co-morbid cirrhosis. The total mortality during index admission and 90-day readmissions as well as the readmissions rate were examined. Adverse events including bleeding, stroke, kidney injury, and vascular complications were also compared. Patients with cirrhosis had a significantly higher number of co-morbidities. The cirrhosis group had a higher overall 90-day mortality (10.3% vs 2.5%, p < 0.01), including during the index hospitalization (7.0% vs 1.8%, p < 0.01), as well as a higher 90-day readmission rate (38.2% vs 20.2%, p < 0.01). Patients with cirrhosis also had higher frequencies of overall 90-day adverse events (44.7% vs 17.7%, p < 0.01), including gastrointestinal bleeding (15.3% vs 2.7%, p < 0.01) and acute kidney injury (28.4% vs 10.1%, p < 0.01). In conclusion, patients with cirrhosis face a significantly higher risk of adverse outcomes including mortality, readmissions, and adverse events in the 90 days after hospitalization for PCI compared with the general population.

A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia

Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.

Cardiovascular Risk Assessment in Renal and Liver Transplant Candidates: A Multidisciplinary Institutional Standardized Approach

In the modern era, renal and liver transplant candidates present with a greater medical complexity driven in part by a higher prevalence of cardiovascular conditions, including coronary artery disease, valvular heart disease, and cardiomyopathies. In fact, cardiovascular disease is the most common cause of death after kidney transplantation worldwide. Similarly, an increase in the number of patients being listed with end-stage liver disease from nonalcoholic steatohepatitis and a rising model for end-stage liver disease scores at the time of liver transplant in the United States parallel an increasing cardiovascular disease risk profile for liver transplant candidates. A large degree of variation exists among clinical practice guidelines and transplant center practice patterns regarding patient selection for routine cardiac testing and the choice of testing modalities. Here, we review the clinical practice guidelines established at our center by a multidisciplinary group, including transplant nephrology, hepatology, and surgery, as well as general and interventional cardiology, with the goal of improving patient selection and reducing adverse cardiac events posttransplant.

Liver transplantation and cardiac illness: Current evidences and future directions

Contraindications to liver transplantation are gradually narrowing. Cardiac illness and chronic liver disease may manifest independently or may be superimposed on each other due to shared pathophysiology. Cardiac surgery involving the cardiopulmonary bypass in patients with Child-Pugh Class C liver disease is associated with a high risk of perioperative morbidity and mortality. Liver transplantation involves hemodynamic perturbations, volume shifts, coagulation abnormalities, electrolyte disturbances, and hypothermia, which may prove fatal in patients with cardiac illness depending upon the severity. Additionally, cardiovascular complications are the major cause of adverse postoperative outcomes after liver transplantation even in the absence of cardiac pathologies. Clinical decision-making has remained an unsettled issue in these clinical scenarios. The absence of randomized clinical studies has further crippled our endeavours for a consensus on the management of patients with end-stage liver disease with cardiac illness. This review seeks to address this complex clinical setting by gathering information from published literature. The management algorithm in this review may facilitate clinical decision making and augur future research.

One-Year Outcomes of Percutaneous Coronary Intervention in Patients with End-Stage Liver Disease

Background:

Patients with cirrhosis and coronary artery disease (CAD) are at high risk for morbidity during surgical revascularization so they are often referred for complex percutaneous coronary intervention (PCI). Percutaneous coronary intervention in the cirrhotic population also has inherent risks; however, quantifiable data on long-term outcomes are lacking.

Methods:

Patients with angiographically significant CAD and cirrhosis were identified from the catheterization lab databases of the University of Pennsylvania Health System between 2007 and 2015. Outcomes were obtained from the medical record and telephonic contact with patients/families.

Results:

Percutaneous coronary intervention was successfully performed in 42 patients (51 PCIs). Twenty-nine patients with significant CAD were managed medically (36 angiograms). The primary outcome (a composite of mortality, subsequent revascularization, and myocardial infarction) was not significantly different between the 2 groups during a follow-up period at 1 year (PCI: 50%, Control: 40%, P = .383). In the PCI group, a composite adverse outcome rate that included acute kidney injury (AKI), severe bleed, and peri-procedural stroke was elevated (40%), with severe bleeding occurring after 23% of PCI events and post-procedural AKI occurring after 26% of events. The medical management group had significantly fewer total matched adverse outcomes (17% vs 40% in the PCI group, P = .03), with severe bleeding occurring after 11% of events and AKI occurring after 6% of events. Increased risk of adverse events following PCI was associated with severity of liver disease by Child-Pugh class.

Conclusions:

Percutaneous coronary intervention in patients with cirrhosis is associated with an elevated risk of adverse events, including severe bleeding and AKI.

Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates

The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.

Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis

OBJECTIVES

We sought to assess the national trends in the utilization and outcomes of percutaneous coronary interventions (PCI) in patients with cirrhosis.

BACKGROUND

Contemporary data on PCI in patients with liver cirrhosis are limited.

METHODS

The National-Inpatient-Sample was used to identify patients who underwent PCI between 2003 and 2016. We examined the annual PCI rate, and compared the in-hospital morbidity, mortality, resource utilization, and cost following PCI in patients with and without cirrhosis.

RESULTS

A total of 8,860,178 PCI hospitalizations were identified, of those, 20,339 (0.2%) were performed in patients with cirrhosis. Annual PCI rates decreased overtime in patients without liver cirrhosis but increased in those with cirrhosis (P_trend < .001). Patients with cirrhosis had a characteristic clinical, demographic, and socioeconomic profile compared with those without cirrhosis. The use of bare-metal stents decreased from 69.1 to 11.4% in the noncirrhosis group, and from 81.9 to 21.3% in the cirrhosis group. Compared with propensity-matched patients without cirrhosis, PCI in cirrhotic patients was associated with higher in-hospital mortality across all indications (STEMI 19.1 vs. 11.5%, p = .002; NSTEMI 8.7 vs. 5.6%, p = .002; and UA/SIHD 7.7 vs. 4.3%, p < .001). Cirrhotic patients also had significantly higher rates of acute kidney injury, but similar rates of vascular complications and stroke. Additionally, cirrhotic patients had longer hospitalizations, were less likely to be discharged home, and accrued higher cost across all PCI indications.

CONCLUSIONS

Patients with cirrhosis who are deemed "suitable PCI candidates" in current practice remain at high-risk for worse short-term morbidity and mortality, and higher cost of care.

Significance of Coronary Artery Calcium Found on Non-Electrocardiogram-Gated Computed Tomography During Preoperative Evaluation for Liver Transplant

Guidelines to evaluate patients for coronary artery disease (CAD) during preoperative evaluation for orthotopic liver transplantation (OLT) are conflicting. Cardiac catheterization is not without risk in patients with end-stage liver disease. No study to date has looked at the utility of non-electrocardiogram-gated chest computed tomography (CT) in the preliver transplant population. Our hypothesis was that coronary artery calcium scores (CACSs) from chest CT scans ordered during the liver transplant workup can identify patients who would benefit from invasive angiography. Nine hundred and fifty-three patients who underwent coronary angiography as part of their OLT workup were considered. Charts were randomly selected and reviewed for the presence of a chest CT performed before coronary angiography during the OLT workup. Agatston and Weston scores were calculated. CACS results were compared with coronary angiography findings. Nine of 54 patients were found to have obstructive CAD by angiography. Receiver-operating characteristic analysis demonstrated that an Agatston score of 251 and a Weston score of 6 maximized sensitivity and specificity for detection of obstructive coronary disease. An Agatston score <4 or Weston score <2 excluded the presence of obstructive CAD; using these thresholds, 13 patients (24%) or 15 patients (28%), respectively, could have theoretically avoided catheterization without missing significant CAD. In conclusion, our data identify the strength of CACS in ruling out coronary disease in patients being evaluated for OLT. Calcium scoring from non-electrocardiogram-gated CT studies may be integrated into preoperative algorithms to rule out obstructive CAD and help avoid invasive angiography in this high-risk population.

Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis

Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years.

Cardiac diseases among liver transplant candidates

Improvements in early survival after liver transplant (LT) have allowed for the selection of LT candidates with multiple comorbidities. Cardiovascular disease is a major contributor to post-LT complications. We performed a literature search to identify the causes of cardiac disease in the LT population and to describe techniques for diagnosis and perioperative management. As no definite guidelines for preoperative assessment (except for pulmonary heart disease) are currently available, we recommend an algorithm for preoperative cardiac work-up.

Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations

Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis, thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

Liver Transplantation in Patients With Cardiac Disease

Liver transplantation (LT) is a unique surgical procedure that has major hemodynamic and cardiovascular implications. Recently, there has been significant interest focused on cardiovascular issues that affect LT patients in all phases of the perioperative period. The preoperative cardiac evaluation is a major step in the selection of LT candidates. LT candidates are aging in concordance with the general population; cardiovascular disease and their risk factors are highly associated with older age. Underlying cardiovascular disease has the potential to affect outcomes in LT patients and has a major impact on candidate selection. The prolonged hemodynamic and metabolic instability during LT may contribute to adverse outcomes, especially in patients with underlying cardiovascular disease. Cardiovascular events are not unusual during LT; transplant anesthesiologists must be prepared for these events. Advanced cardiovascular monitoring techniques and treatment modalities are now routinely used during LT. Postoperative cardiovascular complications are common in both the early and late posttransplant periods. The impact of cardiac complications on posttransplant mortality is well recognized. Emerging knowledge regarding cardiovascular disease in LT patients and its impact on posttransplant outcomes will have an important role in guiding the future perioperative management of LT patients.

Patients with cirrhosis who have coronary artery disease treated with cardiac stents have high rates of gastrointestinal bleeding, but no increased mortality

BACKGROUND

Patients with coronary artery disease (CAD) treated with stents require dual antiplatelet therapy (DAPT). For cirrhotics, who often have varices and coagulopathy, it is not clear if the risk of gastrointestinal bleeding (GIB) should preclude use of DAPT.

AIM

To compare GIB and mortality rates in cirrhotics with CAD treated medically or with stents.

METHODS

Using institutional databases, we identified patients with cirrhosis and CAD treated with stents or medical therapy between January 2000-September 2015. Primary outcomes were GIB and mortality.

RESULTS

We identified 148 cirrhotics with CAD; 68 received stents (cases), 80 were treated with medical therapy (controls). Cases and controls had similar demographics, comorbidities, MELD scores and clinical presentation; DAPT was used in 98.5% of cases vs 5% of controls. The incidence of GIB was significantly higher in cases than controls (22.1% vs 5% at 1 year, P=.003; 27.9% vs 5% at 2 years, P=.0002), whereas all-cause mortality was similar (20.6% vs 21.3%). No patient required surgery or angiography for GIB, and no known patients died due to GIB. Multivariate analysis revealed use of a proton pump inhibitor (PPI) was highly protective against GIB (OR=0.26, 95%CI=0.08-0.79).

CONCLUSIONS

CAD treatment with stents in our cirrhotics was associated with a significantly increased risk of GIB, but no adverse effects on survival. Although it remains unclear whether the cardiovascular benefits of stents outweigh the GIB risk, our findings suggest that DAPT should not be withheld from stented cirrhotics for fear of GIB. Moreover, the use of a PPI should be strongly considered.

International Normalized Ratio Does Not Predict Gastrointestinal Bleeding After Endoscopic Retrograde Cholangiopancreatography in Patients With Cirrhosis

Background

Cirrhosis is often accompanied by an elevated international normalized ratio (INR) due to a decrease in pro-coagulant factors. An elevated INR in cirrhosis is often interpreted as an increased risk of bleeding. There are a paucity of data in the literature on the use of INR to predict risk of gastrointestinal bleeding (GIB) following endoscopic retrograde cholangiopancreatography (ERCP) in patients with cirrhosis. The aims of the study were to determine if there is a correlation between INR and GIB following ERCP in patients with cirrhosis, and to determine if there is a difference in frequency of post-ERCP complications in patients with and without cirrhosis.

Methods

A retrospective review of all ERCP procedures was performed at a tertiary care institution between 2012 and 2015. We identified ERCPs performed in patients with cirrhosis and compared them to a randomly selected group without liver cirrhosis. Univariate analysis was performed using Chi-square and ANOVA tests. A multivariable logistic regression model using generalized estimating equations was used to examine the association between INR and GIB.

Results

There were a total of 1,610 ERCPs performed from 2012 to 2015 with 129 performed in 56 patients with cirrhosis compared with 392 ERCPs performed in 310 patients without cirrhosis. There was no difference in the frequency of GIB following ERCP in both groups (P = 0.117). However, there was a difference in overall complications between both groups (P = 0.007), but no difference observed amongst Child-Turcotte-Pugh classes (P = NS). In a multivariable analysis, sphincterotomy during ERCP (odds ratio (OR) = 3.22; 95% confidence interval (CI): 1.05 - 9.94; P = 0.042) and cirrhosis (OR = 3.58; 95% CI: 1.22 - 10.47; P = 0.02) were significant for predicting GIB. Anti-coagulation (OR = 2.90; 95% CI: 0.82 - 10.23; P = 0.097) and INR were not significant in the multivariable model (OR = 2.09; 95% CI: 0.85 - 5.12; P = 0.10).

Conclusion

There was a statistical difference in overall complications between patients with and without cirrhosis but no difference was observed amongst Child-Turcotte-Pugh classes. Overall, INR was not a significant factor in predicting risk of bleeding in patients after ERCP.

Evaluation of coronary artery disease in potential liver transplant recipients

Improvements in the management of patients undergoing liver transplantation (LT) have resulted in a significant increase in survival in recent years. Cardiac disease is now the leading cause of early mortality, and the stress of major surgery, hemodynamic shifts, and the possibilities of hemorrhage or reperfusion syndrome require the recipient to have good baseline cardiac function. The prevalence of coronary artery disease (CAD) is increasing in LT candidates, especially in those with nonalcoholic fatty liver disease. In assessing LT recipients, we suggest a management paradigm of "quadruple assessment" to include (1) history, examination, and electrocardiogram; (2) transthoracic echocardiogram; (3) functional testing; and (4) where appropriate, direct assessment of CAD. The added value of functional testing, such as cardiopulmonary exercise testing, has been shown to be able to predict posttransplant complications independently of the presence of CV disease. This approach gives the assessment team the greatest chance of detecting and preventing complications related to CAD. Liver Transplantation 23 386-395 2017 AASLD.

Perioperative Cardiovascular Evaluation for Orthotopic Liver Transplantation

Patients with advanced liver disease have a high prevalence of cardiovascular risk factors, but many of them are asymptomatic. Cardiovascular risk stratification prior to liver transplant can be done by dobutamine stress echocardiography, stress myocardial perfusion imaging, cardiac computer tomography, and coronary angiography, but there are no clear recommendations regarding what method should be used and who should be screened. Because of this and because of inherent risk profile in this population, the variations in practice are significant. Careful screening and rigorous management of cardiovascular risk factors are important to ensure optimal cardiovascular outcomes in the immediate post-transplantation period and in the long term as well.

Effectively Screening for Coronary Artery Disease in Patients Undergoing Orthotopic Liver Transplant Evaluation

Coronary artery disease (CAD) is prevalent in patients with end-stage liver disease and associated with poor outcomes when undergoing orthotopic liver transplantation (OLT); however, noninvasive screening for CAD in this population is less sensitive. In an attempt to identify redundancy, we reviewed our experience among patients undergoing CAD screening as part of their OLT evaluation between May 2009 and February 2014. Demographic, clinical, and procedural characteristics were analyzed. Of the total number of screened patients (n = 132), initial screening was more common via stress testing (n = 100; 75.8%) than coronary angiography (n = 32; 24.2%). Most with initial stress testing underwent angiography (n = 52; 39.4%). Among those undergoing angiography, CAD was common (n = 31; 23.5%). Across the entire cohort the number of traditional risk factors was linearly associated with CAD, and those with two or more risk factors were found to have CAD by angiography 50% of the time (OR 1.92; CI 1.07–3.44, p = 0.026). Our data supports that CAD is prevalent among pre-OLT patients, especially among those with 2 or more risk factors. Moreover, we identified a lack of uniformity in practice and the need for evidence-based and standardized screening protocols.

Risk of Bleeding in End-Stage Liver Disease Patients Undergoing Cardiac Catheterization

Patients with end-stage liver disease frequently have baseline coagulopathies. The international normalized ratio is in common use for the estimation of bleeding tendency in such patients, especially those undergoing an invasive procedure like cardiac catheterization. The practice of international normalized ratio measurement-followed by pharmacologic (for example, vitamin K or fresh frozen plasma) or nonpharmacologic intervention-is still debatable. The results of multiple randomized trials have shown the superiority of the radial approach over femoral access in reducing catheterization bleeding. This reduction in bleeding in turn decreases the risk and cost of blood-product transfusion. However, there is little evidence regarding the use of the radial approach in the end-stage liver disease patient population specifically. In this review, we summarize the studies that have dealt with cardiac catheterization in patients who have end-stage liver disease. We also discuss the role of the current measurements that are used to reduce the risk of bleeding in these same patients.

Role of cardiac catheterization and percutaneous coronary intervention in the preoperative assessment and management of patients before orthotopic liver transplantation

Limited data regarding the optimal risk assessment strategy for evaluating candidates for orthotopic liver transplantation (OLT) exist. Our center has adopted a policy of performing cardiac catheterization (CATH) in patients with predefined risk factors, and this is followed by percutaneous coronary intervention (PCI) when it is indicated, even in the presence of negative stress test findings. The aim of this single-center, retrospective study of all patients who underwent OLT between 2000 and 2010 was to assess the effect of our policy on cardiovascular (CV) complications and survival rates after OLT. Data, including 1-year all-cause and CV mortality, postoperative myocardial infarctions (MIs), and frequencies of CATH and PCI, were abstracted. The study was divided into 3 subperiods to reflect the changes in policy over this period: (A) 2000-2004, (B) 2005-2008, and (C) 2009-2010. One thousand two hundred twenty-one patients underwent OLT between 2000 and 2010. The rate of catheterization increased during the 3 time periods (P < 0.001), as did the rate of PCI (P < 0.05). All-cause mortality decreased over the periods (P < 0.001), as did the MI rate (P < 0.001). Thirty-five of the 57 patients requiring PCI had normal stress tests. The mortality rate associated with postoperative MIs was significantly higher than the overall all-cause mortality rate. In conclusion, a significant improvement in the overall survival rate over the 3 analyzed time periods was noted. Increases in the frequencies of CATH and PCI corresponded to significant reductions in postoperative MIs and 1-year all-cause mortality rates. The increased use of CATH and PCI was associated with reduced overall all-cause mortality through reductions in the incidence of both fatal and nonfatal MIs. Further analyses of the role of stress testing and CATH in evaluating and treating patients before OLT are required to optimize this process.

Transradial cardiac catheterization in liver transplant candidates

Transradial (TR) cardiac catheterization is effective and offers lower rates of vascular complications and bleeding compared with transfemoral cardiac catheterization. We sought to describe the safety and feasibility of TR cardiac catheterization in liver transplant candidates (LTCs). We retrospectively reviewed 1,071 consecutive cases of TR cardiac catheterization in 1,045 patients from May 2008 to December 2011 at a single institution. The primary end point was radial approach failure. Ten percent of TR cases (n = 107) were performed in LTCs and 90% (n = 964) were performed in non-LTCs. The LTC group had lower rates of cardiovascular diseases and cardiovascular risk factors. The LTC group had a significantly lower platelet count (75,000 vs 237,000/mm(3), p <0.01), higher international normalized ratio (1.7 vs 1.1, p <0.01), and lower mean arterial pressure (78 vs 89 mm Hg, p <0.01). The mean Model for End-Stage Liver Disease score was 21 in LTCs. Percutaneous coronary interventions were performed in 4% of LTCs and 15% of non-LTCs (p <0.01). The radial approach failure rate was 10% in LTCs and 7% in non-LTCs (p = 0.15). In conclusion, radial approach failure was similar between the LTC and non-LTC groups. Despite significant differences in platelet count and international normalized ratio, there was no difference in the incidence of adverse events between the groups, suggesting that TR cardiac catheterization is safe and effective in LTCs.

Role of baseline echocardiography in the preoperative management of liver transplant candidates

Liver transplantation (LT) has not traditionally been offered to patients with intracardiac shunts (ICSs) or pulmonary hypertension (PH). There is a paucity of data regarding cardiac structural characteristics in LT candidates. We examined echocardiographic characteristics and their role in managing LT candidates diagnosed with ICS and PH. We identified 502 consecutive patients (318 men, mean age 55 ± 11 years) who underwent LT and had preoperative echocardiogram. Demographics, cardiovascular risk factors, and echocardiographic variables were recorded and data were analyzed for end-stage liver disease diagnosis. ICSs were diagnosed with contrast echocardiography and PH was defined as estimated pulmonary artery systolic pressure >40 mm Hg. Primary end points included short-term (30-day) and long-term (mean 41-month) mortalities and the correlation between pre- and perioperative stroke. In our studied population >50% had >2 cardiovascular risk factors and with increasing frequency ICSs were diagnosed in 16%, PH in 25%, and intrapulmonary shunts in 41% of LT candidates. There was no correlation between short- and long-term mortality and ICS (p = 0.71 and 0.76, respectively) or PH (p = 0.79 and 0.71). Importantly, in those with ICS, no strokes occurred. In conclusion, structural differences exist between various end-stage liver disease diagnoses. ICSs diagnosed by echocardiography are not associated with an increased risk of perioperative stroke or increased mortality. A diagnosis of mild or moderate PH on baseline echocardiogram is not associated with worse outcomes and requires further assessment. Based on these findings, patients should not be excluded from consideration for LT based solely on the presence of an ICS or PH.

Usefulness of international normalized ratio to predict bleeding complications in patients with end-stage liver disease who undergo cardiac catheterization

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.

Endoscopic papillary balloon dilation for bile duct stones in patients on hemodialysis

BACKGROUND

Endoscopic papillary balloon dilation (EPBD) is a less hazardous alternative to endoscopic sphincterotomy for managing bile duct stones in patients with a coagulopathy. However, little information on EPBD is available for patients with bile duct stones who are undergoing hemodialysis (HD). We aimed to evaluate the safety and efficacy of EPBD for such patients.

PATIENTS

This was a retrospective cohort study with prospectively collected data for 37consecutive patients with bile duct stones who were undergoing HD and who also underwent EPBD between December 1995 and April 2010 at four institutions in Tokyo, Japan. The main outcome was the safety and efficacy of EPBD for managing bile duct stones in patients undergoing HD.

RESULTS

The bile duct stones were completely removed in one session in 24 patients (64.8%). Overall success was achieved using EPBD alone in all patients. Complications occurred in five patients (13.5%), including two with hemorrhage (5.4%). No hemorrhage developed in any of the 33 patients who had no additional bleeding risk except for HD. Pancreatitis and perforation developed in two (5.4%) and one (2.7%) patient, respectively.

CONCLUSIONS

EPBD seems to be a safe and effective treatment to extract bile duct stones in patients undergoing HD. However, EPBD should be performed carefully in patients with additional bleeding risk factors, such as Child-Pugh class C liver cirrhosis and those taking anti-platelet agents at the time of EPBD.

Coronary artery stents and antiplatelet therapy in patients with cirrhosis

GOALS

To describe our experience with coronary artery stenting and antiplatelet therapy in cirrhotic patients and compare rates of bleeding with a control group.

BACKGROUND

Although there are data on cardiac evaluation and perioperative cardiac risk in cirrhotic patients, there is a paucity of information on outcomes in cirrhotic patients with coronary artery stents. Cirrhotic patients may be at increased risk for complications, including gastrointestinal bleeding as a result of antiplatelet therapy prescribed after stenting.

STUDY

We performed a retrospective study of complications in cirrhotics that received a coronary artery stent followed by clopidogrel and aspirin prescribed to prevent stent occlusion. Cirrhotics with stents were compared with an age and sex-matched control group with cirrhosis without stents and not on aspirin.

RESULTS

Among 423 cirrhotic patients who underwent liver transplant evaluation, 16 patients (3.8%) received a stent of which 9 underwent liver transplant. Two patients with varices (12.5%) in the stent group had fatal variceal bleeding and 2 controls (6.3%) had nonfatal variceal bleeding during follow-up while on antiplatelet therapy (P=0.86). There were no significant differences in transfusion requirements between the 9 liver transplant recipients with stents compared with the control group, P=0.69 for packed red blood cells.

CONCLUSIONS

In our experience, it is safe for cirrhotic patients without varices to receive a coronary artery stent and for cirrhotic patients with coronary artery stents to be considered for liver transplantation. Larger prospective studies are needed to confirm these results and evaluate the risk of bleeding in cirrhotics with varices who receive coronary artery stents and antiplatelet therapy.

Feasibility and safety of percutaneous coronary intervention in patients with end-stage liver disease referred for liver transplantation

Percutaneous coronary intervention (PCI) has traditionally not been an option for patients with end-stage liver disease (ESLD) and coronary artery disease (CAD). This retrospective study was designed to demonstrate the feasibility and safety of PCI in liver transplant candidates. Patients with ESLD and hemodynamically significant CAD who were otherwise deemed to be acceptable candidates for liver transplantation underwent PCI. The procedural success rates, mortality and myocardial infarction rates, and bleeding outcomes were examined. Sixteen patients with ESLD underwent PCI: 15 with bare-metal stents (1.3 stents per patient on average) and 1 with balloon angioplasty alone. The median diameter stenosis per lesion was 80%, the median platelet count was 68 × 10(9) /L, the median international normalized ratio was 1.3, and the median Model for End-Stage Liver Disease score was 13. PCI was successful in 94% of the patients. One patient had a suboptimal residual stenosis of 50% after stenting. There were no in-hospital or 30-day deaths or myocardial infarctions, and no patients developed hematomas. One patient required a 1-U platelet transfusion, and another required 1 U of packed red blood cells. All patients remained clinically stable 1 month after PCI. Nine of the 16 patients were listed for liver transplantation, and 3 patients underwent liver transplantation. In conclusion, we have demonstrated the safety and feasibility of PCI in a small cohort of patients with ESLD and hemodynamically significant CAD, the majority of whom had significant thrombocytopenia. Larger studies are required to determine whether PCI is an effective treatment strategy for patients with ESLD and hemodynamically significant CAD who otherwise would not be candidates for liver transplantation.