Intraoperative Management of Liver Transplantation in Patients with Hypertrophic Cardiomyopathy: A Review

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.

Use of Transesophageal Echocardiography During Orthotopic Liver Transplantation: Simplifying the Procedure

The intraoperative management of patients undergoing orthotopic liver transplantation (OLT) is influenced by the cardiovascular manifestations typically found in the context of end-stage liver disease, by the presence of concomitant cardiovascular disease, and by the significant hemodynamic changes that occur during surgery. Hypotension and intraoperative blood pressure fluctuations during OLT are associated with liver graft dysfunction, acute kidney failure, and increased risk of 30-d mortality. Patients also frequently present hemodynamic instability due to various causes, including cardiac arrest. Recent evidence has shown transesophageal echocardiography (TEE) to be a useful minimally invasive monitoring tool in patients undergoing OLT that gives valuable real-time information on biventricular function and volume status and can help to detect OLT-specific complications or situations. TEE also facilitates rapid diagnosis of life-threatening conditions in each stage of OLT, which is difficult to identify with other types of monitoring commonly used. Although there is no consensus on the best approach to intraoperative monitoring in these patients, intraoperative TEE is safe and useful and should be recommended during OLT, according to experts, for assessing hemodynamic changes, identifying possible complications, and guiding treatment with fluids and inotropes to achieve optimal patient care.

Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view

Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.

Preoperative echocardiography as a prognostic tool for liver transplant in patients with hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) presents with a hypertrophied left ventricle (LV). It is often associated with LV outflow tract obstruction (LVOTO) and a risk for sudden death. This study aimed to describe outcomes of patients with HCM who underwent liver transplant (LT).

METHODS

A retrospective review was conducted for patients diagnosed with HCM undergoing LT. Patient characteristics, preoperative echocardiography results, HCM risk of sudden cardiac death prediction model score, and 5-year mortality were examined. A univariable Cox proportional hazards model was used to evaluate the association between risk factors and 5-year mortality. All tests were two-sided with the alpha level set at .05.

RESULTS

Twenty-nine patients were included in the analysis. Six patients (21%) had a perioperative cardiopulmonary complication. The 5-year survival rate was 61% (95% CI, 45-82). The analyzed risk factors showed that 5-year post-LT survival was significantly predicted by maximal LV outflow tract gradient at rest > 60 mmHg (hazard ratio, 1.04 [95% CI, 1.01-1.06]).

CONCLUSIONS

Preoperative LV outflow tract resting gradient > 60 mmHg was associated with 5-year post-LT mortality. The results suggest the severity of LVOTO identified by echocardiography is a prognostic tool for patients with HCM after LT.

Hypertrophic Cardiomyopathy in Liver Transplantation Patients

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disorder that presents with a hypertrophied nondilated left ventricle. In the absence of other known causes of cardiomyopathy, it is often associated with left ventricular outflow tract obstruction during systole, systolic anterior motion of the mitral valve, mitral regurgitation, and increased risk of sudden cardiac death. When HCM coexists with end-stage liver disease, it can be further complicated by cirrhosis-associated cardiovascular abnormalities, including hyperdynamic circulation, systolic and diastolic dysfunction, and electrophysiologic abnormalities.

METHODS

We retrospectively examined patient characteristics, comorbidities, preoperative echocardiogram results, sudden cardiac death risk prediction model score, and 1-year postoperative mortality of patients with HCM who underwent liver transplantation at our institution from January 1, 2000, through January 1, 2015.

RESULTS

Of the 2,812 liver transplantations performed during the study period, we identified 15 patients with a preoperative diagnosis of HCM. When comparing the patients who did vs did not survive the first year after orthotopic liver transplantation, we identified significant differences in maximal left ventricular wall thickness (P = .004) and resting left ventricular outflow tract gradient (P = .004). Preoperative left atrium size (measured by echocardiography; P = .66) and the sudden cardiac death risk prediction model score (P = .32) were not significantly associated with 1-year survival.

CONCLUSIONS

Preoperative left ventricular outflow tract gradient exceeding 60 mm Hg was strongly associated with death during the first year after transplant. These results suggest that the severity of HCM influences patient outcomes.

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.

Perioperative Anesthetic Management of Patients Having Liver Transplantation for Uncommon Conditions

This review focuses on the perioperative anesthetic management of patients having liver transplantation (LT) performed for several uncommon indications or in combination with rare pathology. Conditions discussed in the article include Alagille syndrome, hypertrophic cardiomyopathy, Gilbert's syndrome, porphyria, Wilson's disease, and Budd-Chiari syndrome. In comparison to other indications, LT in these settings is infrequent because of the low incidence of these pathologies. Most of these conditions (with the exception of Gilbert syndrome) are associated with a high probability of significant perioperative complications and increased mortality and morbidity. Experience in management of these unusual conditions is only gained over time. Developing clinical pathways for patients with these conditions should result in outcomes similar to LT performed for more common indications.

Anesthesia for Liver Transplantation

The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, and the impact of ischemia-reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.

Harmful effect of epinephrine on postreperfusion syndrome in an elderly liver transplantation recipient with sigmoid ventricular septum: A case report

INTRODUCTION

As a common morphological change of aging heart, sigmoid ventricular septum is frequently found during routine preoperative evaluation, but often disregarded because of its little clinical importance. However, in this report, we describe a 70-year old patient with sigmoid ventricular septum who developed severe hemodynamic deterioration during liver transplantation because of its unique morphology of heart.

METHODS

During the course of reperfusion of the graft, patient's hemodynamics were closely monitored using transesophageal echocardiography.

RESULTS

Immediately after graft reperfusion, epinephrine was given as a treatment of choice for postreperfusion syndrome. Surprisingly, however, hemodynamic derangement persisted and became even worse. Intraoperative transesophageal echocardiography revealed left ventricular outflow tract obstruction resulting from systolic anterior motion of the mitral valve leaflet. Therefore, the patient was treated with phenylephrine and fluid bolus under the guidance of transesophageal echocardiography.

CONCLUSION

As more elderly recipient present for liver transplantation surgery nowadays, left ventricular outflow tract obstruction should always be considered as a possible cause for hemodynamic instability during reperfusion period. In addition, transesophageal echocardiography is a useful tool for both diagnosis of hemodynamic derangement and guidance for appropriate management during liver transplantation surgery.

Atrioventricular Sequential Pacing for Hypertrophic Cardiomyopathy During Liver Transplantation

Hypertrophic cardiomyopathy is a myocardial disorder that carries an increased risk of morbidity and mortality during liver transplantation. We describe the use of atrioventricular sequential pacing, placed preoperatively, to assist with intraoperative management of a patient with severe refractory hypertrophic cardiomyopathy undergoing orthotopic piggyback liver transplantation. We discuss the pathogenesis and treatment of this infrequent but serious comorbidity.

Safety of Noncardiac Surgery in Patients With Hypertrophic Obstructive Cardiomyopathy at a Tertiary Care Center

OBJECTIVES

This study's purpose was to review non-cardiac surgery (NCS) in patients with hypertrophic obstructive cardiomyopathy (HOCM) to examine perioperative management and quantify postoperative mortality and worsening heart failure.

DESIGN

Retrospective review.

SETTING

A single tertiary care center.

PARTICIPANTS

The study included 57 adult patients with HOCM who underwent NCS from January 1, 1996, through January 31, 2014.

INTERVENTIONS

Noncardiac surgery.

MEASUREMENTS AND MAIN RESULTS

The authors identified 57 HOCM patients who underwent 96 NCS procedures. Vasoactive medications were administered to the majority of NCS patients. Three patients (3%) died within 30 days of NCS, but causes of death did not appear to be cardiac in nature. Death after NCS was not significantly associated with preoperative left ventricular ejection fraction (p = 0.2727) or peak instantaneous systolic resting gradient (0.8828), but was associated with emergency surgery (p = 0.0002). Three patients experienced worsening heart failure postoperatively, and this was significantly associated with preoperative New York Heart Association Class III-IV symptoms compared with I-II symptoms (p = 0.0008).

CONCLUSIONS

HOCM patients safely can undergo NCS at multidisciplinary centers experienced in caring for these patients. The mortality rate in this study was less than that reported in the majority of other studies. Postoperative complications, including increasing heart failure, may occur, especially in patients with more severe preoperative cardiac symptoms.