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Kassab K, Doukky R. Cardiac imaging for the assessment of patients being evaluated for liver transplantation. J Nucl Cardiol 2022; 29:1078-1090. [PMID: 33825142 DOI: 10.1007/s12350-021-02591-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
Cardiac risk assessment prior to liver transplantation has become widely accepted. With the emergence of nonalcoholic steatohepatitis among the leading causes of end-stage liver disease and the steady rise of the age of liver transplant recipients, the burden of cardiovascular diseases has markedly increased in this population. Selecting appropriate liver transplant candidates is crucial due to the increasing demand for scarce donor organs. The use of noninvasive cardiac imaging for pre-operative assessment of the cardiovascular status of liver transplant recipients has been on the rise, yet the optimal assessment strategy remains an area of active debate. In this review, we examine the relevant literature pertaining to the diagnostic and prognostic applications of noninvasive cardiac imaging in this population. We also propose a simple literature-based evaluation algorithm for CAD surveillance in liver transplant candidates.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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2
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Moody WE, Holloway B, Arumugam P, Gill S, Wahid YS, Boivin CM, Thomson LE, Berman DS, Armstrong MJ, Ferguson J, Steeds RP. Prognostic value of coronary risk factors, exercise capacity and single photon emission computed tomography in liver transplantation candidates: A 5-year follow-up study. J Nucl Cardiol 2021; 28:2876-2891. [PMID: 32394403 PMCID: PMC8709822 DOI: 10.1007/s12350-020-02126-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/22/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although consensus-based guidelines support noninvasive stress testing prior to orthotopic liver transplantation (OLT), the optimal screening strategy for assessment of coronary artery disease in patients with end-stage liver disease (ESLD) is unclear. This study sought to determine the relative predictive value of coronary risk factors, functional capacity, and single photon emission computed tomography (SPECT) on major adverse cardiovascular events and all-cause mortality in liver transplantation candidates. METHODS Prior to listing for transplantation, 404 consecutive ESLD patients were referred to a University hospital for cardiovascular (CV) risk stratification. All subjects met at least one of the following criteria: inability to perform > 4 METs by history (62%), insulin-treated diabetes mellitus (53%), serum creatinine > 1.72 mg/dL (8%), history of MI, PCI or CABG (5%), stable angina (3%), cerebrovascular disease (1%), peripheral vascular disease (1%). Subjects underwent Technetium-99m SPECT with multislice coronary artery calcium scoring (CACS) using exercise treadmill or standard adenosine stress in those unable to achieve 85% maximal heart rate (Siemens Symbia T16). Abnormal perfusion was defined as a summed stress score (SSS) ≥ 4. RESULTS Of the 404 patients, 158 (age 59 ± 9 years; male 68%) subsequently underwent transplantation and were included in the primary analysis. Of those, 50 (32%) died after a mean duration follow-up of 5.4 years (maximal 10.9 years). Most deaths (78%) were attributed to noncardiovascular causes (malignancy, sepsis, renal failure). Of the 32 subjects with abnormal perfusion (20%), nine (6%) had a high-risk perfusion abnormality defined as a total perfusion defect size (PDS) ≥ 15% and/or an ischemic PDS ≥ 10%. Kaplan-Meier survival curves demonstrated abnormal perfusion was associated with increased CV mortality (generalized Wilcoxon, P = 0.014) but not all-cause death. Subjects with both abnormal perfusion and an inability to exercise > 4 METs had the lowest survival from all-cause death (P = 0.038). Abnormal perfusion was a strong independent predictor of CV death (adjusted HR 4.2; 95% CI 1.4 to 12.3; P = 0.019) and MACE (adjusted HR 7.7; 95% CI 1.4 to 42.4; P = 0.018) in a multivariate Cox regression model that included age, sex, diabetes, smoking and the ability to exercise > 4 METs. There was no association between CACS and the extent of perfusion abnormality, nor with outcomes. CONCLUSIONS Most deaths following OLT are noncardiovascular. Nonetheless, abnormal perfusion is prevalent in this high-risk population and a stronger predictor of cardiovascular morbidity and mortality than functional status. A combined assessment of functional status and myocardial perfusion identifies those at highest risk of all-cause death. (Exercise Capacity and Single Photon Emission Computed Tomography in Liver Transplantation Candidates [ExSPECT]; ClinicalTrials.gov Identifier: NCT03864497).
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Affiliation(s)
- William E Moody
- Department of Nuclear Medicine, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Edgbaston, B15 2TH, UK.
| | - Benjamin Holloway
- Department of Nuclear Medicine, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Edgbaston, B15 2TH, UK
| | - Parthiban Arumugam
- Department of Nuclear Medicine, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - Sharon Gill
- Department of Nuclear Medicine, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Edgbaston, B15 2TH, UK
| | - Yasmin S Wahid
- Department of Nuclear Medicine, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Edgbaston, B15 2TH, UK
| | - Chris M Boivin
- Department of Nuclear Medicine, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Edgbaston, B15 2TH, UK
| | - Louise E Thomson
- Departments of Imaging and Medicine, S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine, S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Matthew J Armstrong
- Department of Liver Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, B15 2TH, UK
- Institute of Immunology and Immunotherapy, National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
| | - James Ferguson
- Department of Liver Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, B15 2TH, UK
- Institute of Immunology and Immunotherapy, National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
| | - Richard P Steeds
- Department of Nuclear Medicine, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Edgbaston, B15 2TH, UK
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Gomez J. SPECT-MPI in evaluation of liver transplant candidates: Is the evidence mounting? J Nucl Cardiol 2021; 28:2892-2894. [PMID: 32566964 DOI: 10.1007/s12350-020-02240-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Javier Gomez
- Division of Cardiology, John H. Stroger Jr, Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA.
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Bonou M, Mavrogeni S, Kapelios CJ, Skouloudi M, Aggeli C, Cholongitas E, Papatheodoridis G, Barbetseas J. Preoperative Evaluation of Coronary Artery Disease in Liver Transplant Candidates: Many Unanswered Questions in Clinical Practice. Diagnostics (Basel) 2021; 11:diagnostics11010075. [PMID: 33466478 PMCID: PMC7824885 DOI: 10.3390/diagnostics11010075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular (CV) complications represent the first non-graft-related cause of death and the third overall cause of death among patients undergoing liver transplantation (LT). History of coronary artery disease is related to increased CV mortality following LT. Although it is of paramount importance to stratify CV risk in pre-LT patients, there is no consensus regarding the choice of the optimal non-invasive cardiac imaging test. Algorithms proposed by scientific associations include non-traditional risk factors, which are associated with increased cardiac risk profiles. Thus, an individualized pre-LT evaluation protocol should be followed. As the average age of patients undergoing LT and the number of candidates continue to rise, the “3 W” questions still remain unanswered, Who, Which and When? Who should be screened for coronary artery disease (CAD), which screening modality should be used and when should the asymptomatic waitlisted patients repeat cardiac evaluation? Prospective studies with large sample sizes are warranted to define an algorithm that can provide better risk stratification and more reliable survival prediction.
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Affiliation(s)
- Maria Bonou
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
| | - Sophie Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, 17674 Athens, Greece;
| | - Chris J. Kapelios
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
- Correspondence: or ; Tel.: +30-213-2061032; Fax: +30-213-2061761
| | - Marina Skouloudi
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
| | - Constantina Aggeli
- First Department of Cardiology, Hippokration General Hospital, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - George Papatheodoridis
- Department of Gastroenterology, Laiko General Hospital, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - John Barbetseas
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
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