Outcome of Liver Transplant Recipients With Revascularized Coronary Artery Disease: A Comparative Analysis With and Without Cardiovascular Risk Factors. Transplantation. 2017;101:793-803. [PMID: 28099403 DOI: 10.1097/tp.0000000000001647]

[The Role of the Anaesthesiologist in Liver Transplantation - Preoperative Evaluation]

Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.

Screening Modalities for Coronary Artery Disease in Liver Transplant Candidates: A Review of the Literature

Patients with cirrhosis undergoing liver transplant (LT) are at high risk of postoperative cardiopulmonary complications. It is known that patients with coronary artery disease (CAD) have greater rates of post-LT morbidity and mortality than patients without CAD. Thus, identifying significant CAD in LT candidates is of the utmost importance to optimize survival posttransplant. Consensus is lacking on the ideal screening test for CAD in LT candidates. Traditional exercise and many pharmacologic stress tests are impractical and inaccurate in patients with cirrhosis due to their unique physiology. The purpose of this review is to describe different screening modalities for CAD among LT candidates. The background, diagnostic accuracy, and limitations of each screening modality are described to achieve this goal.

Liver Transplantation: Contraindication and Ineligibility

Liver transplantation (LT) is a life-saving therapeutic modality for patients with various advanced liver diseases. It is crucial to identify that the patient's illness is sufficiently advanced and unlikely to improve with medical management to justify the need for transplantation. At the same time, it is crucial to identify patients with comorbidities and far advanced disease that would result in an unacceptable outcome after LT. Specific care also is required before deciding on LT in the elderly, acute on chronic liver disease, patients with comorbidities, and hepatocellular carcinoma. Transplantation needs to be timed appropriately to avoid unnecessary LT and ensure that the decision is not left too late to avoid losing the patient without a transplant. Also, important is the decision as to when not to transplant. The current review explores some of these issues of contraindications and ineligibility for LT.

High Coronary Artery Calcium Score Is Associated With Increased Major Adverse Cardiac Events After Liver Transplantation

Liver transplantation (LT) candidates frequently have multiple cardiovascular risk factors, and cardiovascular disease is a major cause of morbidity and mortality after LT. Coronary artery calcium (CAC) scores are a noninvasive assessment of coronary artery disease using computed tomography. This study examines CAC scores and cardiac risk factors and their association with outcomes after LT.

Methods

Patients who underwent LT between January 2010 and June 2019 with a pretransplant CAC score were included in this study. Patients were divided by CAC score into 4 groups (CAC score 0, CAC score 1-100, CAC score 101-400, CAC score >400). Major adverse cardiovascular events (MACEs) were defined as myocardial infarction, stroke, revascularization, heart failure, atrial fibrillation, and cardiovascular death. Associations between CAC score and MACE or all-cause mortality within the 5-y post-LT follow-up period were analyzed using Cox regression. Statistical significance was defined as P < 0.05.

Results

During the study period, 773 adult patients underwent their first LT, and 227 patients met our study criteria. The median follow-up time was 3.4 (interquartile range 1.9, 5.3) y. After 5 y, death occurred in 47 patients (20.7%) and MACE in 47 patients (20.7%). In multivariable analysis, there was no difference in death between CAC score groups. There was significantly higher risk of MACE in the CAC score >400 group, with a hazard ratio 2.58 (95% confidence interval 1.05, 6.29).

Conclusions

CAC score was not associated with all-cause mortality. Patients with CAC score >400 had an increase in MACEs within the 5-y follow-up period compared with patients with a CAC score = 0. Further research with larger cohorts is needed to examine cardiac risk stratification in this vulnerable patient population.

Outcomes of Liver Transplantation in Patients with Preexisting Coronary Artery Disease

BACKGROUND

Advances in surgical and medical technology over the years has made liver transplantation possible for older and higher risk patients. Despite rigorous preoperative cardiac testing, cardiovascular events remain a major cause of death after orthotopic liver transplantation (OLT). However, there are little data on the outcomes of OLT in patients with preexisting coronary artery disease (CAD). This study aimed to compare all-cause and cardiovascular mortality of patients with and without history of CAD undergoing OLT.

METHODS

Six hundred ninety-three adult patients with cirrhosis underwent liver transplantation between July 2013 and December 2018 (female n = 243, male n = 450; median age 59).

RESULTS

During the study period of 5 y (median follow-up, 24.1 mo), 92 of 693 patients (13.3%) died. All-cause mortality in the CAD group was significantly higher than in the non-CAD group (26.7% versus 9.6%; P <0.01). Cardiovascular events accounted for 52.5% of deaths (n = 21) in patients with CAD compared with 36.5% (n = 19) in non-CAD patients. At 6 mo, patients with combined nonalcoholic steatohepatitis (NASH)/CAD had significantly worse survival than those with CAD or NASH alone ( P <0.01). After 6 mo, patients with CAD alone had similar survival to those with combined NASH/CAD.

CONCLUSIONS

Patients with preexisting CAD before liver transplantation are at higher risk of death from any cause, specifically cardiovascular-related death. This risk increases with coexisting NASH. The presence of NASH and CAD at the time of liver transplant should prompt the initiation of aggressive risk factor modification for patients with CAD.

Consensus Statement on Hemostatic Management, Anticoagulation, and Antiplatelet Therapy in Liver Transplantation

Anticoagulation and antiplatelet therapies are increasingly used in liver transplant (LT) candidates and recipients due to cardiovascular comorbidities, portal vein thrombosis, or to manage posttransplant complications. The implementation of the new direct-acting oral anticoagulants and the recently developed antiplatelet drugs is a great challenge for transplant teams worldwide, as their activity must be monitored and their complications managed, in the absence of robust scientific evidence. In this changing and clinically heterogeneous scenario, the Spanish Society of Liver Transplantation and the Spanish Society of Thrombosis and Haemostasis aimed to achieve consensus regarding the indications, drugs, dosing, and timing of anticoagulation and antiplatelet therapies initiated from the inclusion of the patient on the waiting list to post-LT surveillance. A multidisciplinary group of experts composed by transplant hepatologists, surgeons, hematologists, transplant-specialized anesthesiologists, and intensivists performed a comprehensive review of the literature and identified 21 clinically relevant questions using the patient-intervention-comparison-outcome format. A preliminary list of recommendations was drafted and further validated using a modified Delphi approach by a panel of 24 transplant delegates, each representing a LT institution in Spain. The present consensus statement contains the key recommendations together with the core supporting scientific evidence, which will provide guidance for improved and more homogeneous clinical decision making.

Cardiac imaging for the assessment of patients being evaluated for liver transplantation

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.

A Comprehensive Review on the Risk of Metabolic Syndrome and Cardiovascular Disease after Liver Transplantation

Survival rates after liver transplantation have increased dramatically over the past 20 years. Cardiovascular disease is the most common extra-hepatic cause of mortality in the long-term post liver transplant. This is intimately linked with both the higher pre-existing rates of metabolic syndrome in these patients as well as increased propensity to develop de novo metabolic syndrome post-transplant. This unfavorable metabolic profile that contributes to cardiovascular disease is multifactorial and largely preventable. This review explores metabolic syndrome and cardiovascular disease and their contributory factors post liver transplantation to highlight areas for potential intervention and thus reduce the significant morbidity and mortality of patients due to metabolic syndrome and cardiovascular disease.

A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients

The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.

Diagnostic Yield of Coronary Angiography in Asymptomatic Orthotopic Liver Transplantation Candidates

BACKGROUND

The ideal cardiac risk stratification strategy for orthotopic liver transplantation (OLT) is unknown. Our institution performed coronary angiography for asymptomatic OLT candidates at high risk for CAD: ≥65 years of age, diabetic and ≥55 years of age or diagnosed ≥5 years, abnormal stress test, or at the discretion of the OLT committee.

METHODS

The analysis included 301 consecutive, asymptomatic OLT candidates who underwent coronary angiography. The primary outcome was the prevalence of obstructive CAD.

RESULTS

At 2-year follow-up, OLT was performed in 44.9%, and 42.2% died. The prevalence of obstructive CAD, involvement of the proximal or mid LAD, and 3-vessel CAD were 10.3%, 6.6%, and 0.7%, respectively. Percutaneous and surgical revascularization were performed in 7.0% and 1.3%, respectively. Stress test was performed in 54.8%. The sensitivity and specificity of stress testing were 0% and 87.1%, respectively. The negative and positive predictive values of stress testing were 91.4% and 0%, respectively. Chest computed tomography (CT) was performed in 83.1%. Moderate or severe coronary artery calcification (CAC) was present in 47.8%. The sensitivity and specificity of moderate or severe CAC were 88.9% and 57.3%, respectively. The negative and positive predictive values of moderate or severe CAC were 97.7% and 20.2%, respectively. Multivariate analysis demonstrated that CAC was an independent predictor of obstructive CAD (HR 10.7; 95% CI 3.2-37.9; p < 0.001).

CONCLUSIONS

The prevalence of obstructive CAD in asymptomatic OLT candidates at high risk was uncommon. Alternative diagnostic strategies may be preferred to coronary angiography.

Prognostic value of coronary risk factors, exercise capacity and single photon emission computed tomography in liver transplantation candidates: A 5-year follow-up study

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).

Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease

The prevalence of coronary artery disease (CAD) increases in patients with end-stage liver disease, with part of them receiving the percutaneous coronary intervention (PCI) as a treatment option. Dual antiplatelet therapy (DAPT), a standard of care after PCI, could result in catastrophic consequences in this population. Before PCI and the start of DAPT, it is recommended to assess patient bleeding risk. Based on novel findings, liver cirrhosis does not necessarily lead to a significant increase in bleeding complications. Furthermore, conventional methods, such as the international normalized ratio, might not be appropriate in assessing individual bleeding risk. The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia (< 50 × 10⁹/L) and elevated portal pressure. Therefore, every effort should be made to maintain thrombocyte count above > 50 × 10⁹/L and prevent variceal bleeding. There is no solid evidence for DAPT in patients with cirrhosis. However, randomized trials investigating short (one month) DAPT duration after PCI with new drug-eluting stents (DES) in a high bleeding risk patient population can be implemented in patients with cirrhosis. Based on retrospective studies (with older stents and protocols), PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage. Finally, novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT. When indicated, PCI should be performed over radial artery using contemporary DES. Complementary medical therapy, such as proton pump inhibitors and beta-blockers, should be prescribed for lower bleeding risk patients. Novel approaches, such as thromboelastography and “preventive” upper endoscopies in PCI circumstances, warn clinical confirmation.

Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions

In the changing landscape of liver transplantation (LT), we are now evaluating older and sicker patients with more cardiovascular comorbidities, and the spectrum of cardiovascular disease is uniquely physiologically impacted by end-stage liver disease. Cardiac complications are now the leading cause of morbidity and mortality in LT recipients, and the pretransplant risk is exacerbated immediately during the transplant operation and continues long term under the umbrella of immunosuppression. Accurate risk estimation of cardiac complications before LT is paramount to guide allocation of limited health care resources and to improve both short-term and long-term clinical outcomes for patients. Current screening and diagnostic testing are limited in their capacity to accurately identify early coronary disease and myocardial dysfunction in persons with end-stage liver disease physiology. Furthermore, a number of testing modalities have not been evaluated in patients with end-stage liver disease. As a result, there is wide variation in cardiac risk assessment practices across transplant centers. In this review, we propose a definition for defining cardiac events in LT, evaluate the current evidence for surgery-related, short-term and long-term cardiac risk assessment in LT candidates, propose an evidence-based testing algorithm, and highlight specific gaps in knowledge and current controversies, identifying areas for future research.

Utility of Framingham Score for Optimizing Preoperative Evaluation Among Patients Undergoing Liver Transplant Evaluation

BACKGROUND

Cardiac testing of candidates for liver transplant (LT) requires balancing risks and benefits of cardiac procedures. The goal of this study was to evaluate the utility of the Framingham score (FS) for optimizing preoperative risk stratification for coronary artery disease (CAD).

METHODS

In this single-center retrospective study of 615 adults undergoing LT evaluation from 2016 to 2019, data of preoperative evaluation, post-LT 1-year mortality, and post-LT cardiac events were reviewed. Patients >30 years of age with normal echocardiogram underwent FS calculation. Elevated FS (≥35%) patients were triaged to undergo angiogram for CAD evaluation; FS <35% patients underwent stress testing as initial CAD evaluation.

RESULTS

Of 615 patients referred for LT, 481 underwent cardiac testing. Ninety-five were excluded from the FS pathway because of age, abnormal baseline echocardiogram, or known CAD. Of the remaining 386 patients in the FS pathway, 342 had a low FS and 44 had a high FS. In patients with low FS, 90% underwent stress testing as initial test; 16% underwent invasive testing at some time. In those with elevated FS, 59% underwent invasive testing as initial test. Listing rate and posttransplant outcomes were similar between patients with low and high FS.

CONCLUSION

We demonstrated the feasibility of a simple algorithmic evaluation process using FS for optimizing pre-LT risk stratification for CAD. Although exceptions to the protocol occur, the proposed protocol allows for a streamlined approach by prioritizing testing based on cardiac risk. This approach may maximize diagnostic yield while limiting invasive procedures.

Cardiac evaluation of the kidney or liver transplant candidate

PURPOSE OF REVIEW

As the field of transplant has advanced, cardiac events have become the leading cause of morbidity and mortality after liver and kidney transplantation ahead of graft failure and infection. This trend has been bolstered by the transplantation of older and sicker patients who have a higher burden of cardiovascular risk factors, accentuating the need to determine which patients should undergo more extensive cardiac evaluation prior to transplantation.

RECENT FINDINGS

Computed tomography coronary angiography with or without coronary artery calcium scoring is now preferred over stress imaging in most transplant candidates for assessment of coronary artery disease. Assessment of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended, particularly in liver transplant candidates who are at high risk of cirrhotic cardiomyopathy, for which new diagnostic criteria were recently published in 2019.

SUMMARY

Cardiac evaluation of liver and kidney transplant candidates requires a global assessment for both short and long-term risk for cardiac events. Imaging of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended. Risk stratification should consider both the anatomic and functional consequences of coronary artery disease in transplant candidates.

VIDEO ABSTRACT

http://links.lww.com/MOT/A27.

Incidence, Predictors, and Impact on Survival of Long-term Cardiovascular Events After Liver Transplantation

BACKGROUND

Information on the risk factors, particularly kidney function, and impact of long-term cardiovascular events (CVE) after liver transplantation (LT) remains scarce.

METHODS

This is a retrospective, single-center study that included consecutive LT recipients between 2007 and 2017. The incidence of CVE, their risk factors, and their impact on patient survival were investigated.

RESULTS

We included 627 LT recipients. The incidence of CVE was 8% and 20% at 12 and 60 months after LT, respectively. The independent risk factors of long-term (beyond 12 mo) CVE were age at LT (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.07), male gender (HR, 2.48; 95% CI, 1.21-5.05), history of pre-LT cardiovascular disease (HR, 2.19; 95% CI, 1.2-3.98), and immunosuppression with cyclosporine A (HR, 1.93; 95% CI, 1.14-3.3). In patients with pre-LT cardiovascular disease, creatinine levels 12 months after LT significantly impacted the risk of long-term CVE. Long-term CVE (HR, 2.12; 95% CI, 1.24-3.61), hepatitis C as the etiology of liver disease (HR, 2.18; 95% CI, 1.29-3.67), cytomegalovirus infection (HR, 1.89; 95% CI, 1.08-3.3), and donor age (HR, 1.02; 95% CI, 1.01-1.04) were independent factors associated with post-LT patient death.

CONCLUSIONS

Age, male gender, cardiovascular disease before LT, and cyclosporine A were associated with the risk of long-term CVE. The impact of serum creatinine was restricted to patients with pre-LT cardiovascular disease. In these patients, preservation of kidney function early after LT may lessen the incidence of CVE, which are an independent predictor of post-LT death.

Presence of any degree of coronary artery disease among liver transplant candidates is associated with increased rate of post-transplant major adverse cardiac events

The impact of coronary artery disease (CAD) among liver transplant candidates (LTC) on post-LT clinical outcomes remains unclear. The aim of this study is to determine association of presence and severity of CAD on post-LT major adverse cardiac events (MACE) including cardiac-associated mortality. We conducted a retrospective cohort analysis of 231 patients who underwent diagnostic coronary angiogram (DCA) during their LT evaluation at a tertiary medical center from 2012-2017. Patients were analyzed based on degree of CAD (no CAD, non-obstructive CAD [< 50% stenosis], obstructive CAD [≥50% stenosis]) per DCA results. MACE were noted at 30 days, 1 year, 3 years, and 5 years post-LT, and Kaplan-Meier curves were used to determine post-LT MACE-free probability. LTC with any CAD, including non-obstructive CAD, had lower MACE-free probability at all post-LT time points (0.94 vs 0.65 at 30 days, P = .001; 0.87 vs 0.59 at 1 year, P = .002; 0.87 vs 0.41 at 3 years, P < .001; 0.87 vs 0.37 at 5 years, P < .001). Identification of and medical intervention for non-obstructive CAD should be considered in all LTC, though further studies are necessary to determine optimal medical interventions to mitigate MACE risk in this cohort.

Pathogenesis of non-alcoholic fatty liver disease and implications on cardiovascular outcomes in liver transplantation

Along with the obesity epidemic there has been a major increase in non-alcoholic fatty liver disease (NAFLD) prevalence, paralleling a steady increase in cirrhosis of the liver and hepatocellular cancer (HCC) related to NAFLD. Currently, NAFLD (related HCC and cirrhosis) is the second most common cause for liver transplantation (LT) and it is projected to take the top spot in the next 3-5 years. Patients with NAFLD cirrhosis and HCC have a unique set of comorbidities which potentially increases their risk for cardiovascular disease (CVD) and mortality. However, a review of the published data in NAFLD patients who undergo LT, does not paint a clear picture. While CVD is the most common cause of non-graft related mortality over the long-term, the short and intermediate-term survival post LT in NAFLD cirrhosis appears to be on par with other etiologies when age and comorbidities are factored. The cardiovascular complications are increased in the immediate post-transplant period but there is a shift from ischemic complications to arrhythmias and heart failure (HF). NAFLD recurs in 80-100% patients and occurs de novo in about 50% after LT, potentially impacting their long-term morbidity and mortality. This review summarizes the available data on CVD in NAFLD patients before and after LT, explains what is currently known about the epidemiology and pathogenesis of CVD in NAFLD and posits strategies to improve wait-list and post-transplant survival.

Pre-Liver Transplant Cardiac Catheterization Is Associated With Low Rate of Myocardial Infarction and Cardiac Mortality

BACKGROUND AND AIMS

A study at Indiana University demonstrated a reduction in myocardial infarction (MI) incidence with increased frequency of cardiac catheterization (CATH) in liver transplant (LT) candidates. A strict protocol for performing CATH based upon predefined risk factors, rather than noninvasive testing alone, was applied to a subgroup (2009-2010) from that study. CATH was followed by percutaneous coronary intervention (PCI) in cases of significant coronary artery disease (CAD; ≥50% stenosis). The current study applies this screening protocol to a larger cohort (2010-2016) to assess post-LT clinical outcomes.

APPROACH AND RESULTS

Among 811 LT patients, 766 underwent stress testing (94%) and 559 underwent CATH (69%), of whom 10% had CAD requiring PCI. The sensitivity of stress echocardiography in detecting significant CAD was 37%. Predictors of PCI included increasing age, male gender, and personal history of CAD (P < 0.05 for all). Compared to patients who had no CATH, patients who underwent CATH had higher mortality (P = 0.07), and the hazard rates (HR) for mortality increased with CAD severity (normal CATH, HR, 1.35; 95% confidence interval [CI], 0.79-2.33; P = 0.298; nonobstructive CAD, HR, 1.53; 95% CI, 0.84-2.77; P = 0.161; and significant CAD, HR, 1.96; 95% CI, 0.93-4.15; P = 0.080). Post-LT outcomes were compared to the 2009-2010 subgroup from the previous study and showed similar 1-year overall mortality (8% and 6%, P = 0.48), 1-year MI incidence (<1% and <1%, P = 0.8), and MI deaths as a portion of all deaths (3% and 9%, P = 0.35).

CONCLUSIONS

Stress echocardiography alone is not reliable in screening LT patients for CAD. Aggressive CAD screening with CATH is associated with low rate of MI and cardiac mortality and validates the previously published protocol when extrapolated over a larger sample and longer follow-up period.

Medical management of metabolic and cardiovascular complications after liver transplantation

Liver transplantation represents the only curative option for patients with end-stage liver disease, fulminant hepatitis and advanced hepatocellular carcinoma. Even though major advances in transplantation in the last decades have achieved excellent survival rates in the early post-transplantation period, long-term survival is hampered by the lack of improvement in survival in the late post transplantation period (over 5 years after transplantation). The main etiologies for late mortality are malignancies and cardiovascular complications. The latter are increasingly prevalent in liver transplant recipients due to the development or worsening of metabolic syndrome and all its components (arterial hypertension, dyslipidemia, obesity, renal injury, etc.). These comorbidities result from a combination of pre-liver transplant features, immunosuppressive agent side-effects, changes in metabolism and hemodynamics after liver transplantation and the adoption of a sedentary lifestyle. In this review we describe the most prevalent metabolic and cardiovascular complications present after liver transplantation, as well as proposing management strategies.

Preoperative cardiac assessment in liver transplant candidates

New and extended indications, older age, higher cardiovascular risk, and the long-standing cirrhosis-associated complications mandate specific skills for an appropriate preoperative assessment of the liver transplant (LT) candidate. The incidence of cardiac diseases (dysrhythmias, cardiomyopathies, coronary artery disease, valvular heart disease) are increasing among LT recipients: however, no consensus exists among clinical practice guidelines for cardiovascular screening and risk stratification. In spite of different "transplant center-centered protocols", basic "pillars" are common (electrocardiography, baseline echocardiography, functional assessment). Owing to intrinsic limitations, yields and relevance of noninvasive stress tests, under constant scrutiny even if used, are discussed, focusing the definition of the "high risk" candidate and exploring noninvasive imaging and new forms of stress imaging. The aim is to find an appropriate and rational stepwise algorithm. The final commitment is to select the right candidate for a finite resource, the graft, able to save (and change) lives.

Intraoperative management and early post-operative outcomes of patients with coronary artery disease who underwent orthotopic liver transplantation

BACKGROUND

Coronary artery disease (CAD) is frequently observed in aging end-stage liver disease (ESLD) patients who require orthotopic liver transplantation (OLT). This situation is challenging for both the patients and the medical staff.

METHODS

We retrospectively studied the case records of 26 ESLD patients with CAD who underwent OLT with total clamping of the inferior vena cava between 2014 and 2018. We analyzed the details of the pre-operative evaluation, intraoperative anesthetic management and post-operative prognosis of these patients.

RESULTS

All patients tolerated the anhepatic stage well. Post-reperfusion syndrome (PRS) was observed in 13 patients (50%) and 2 of them were severe but corrected well. ST-segment depression was frequently observed during the anhepatic stage and reperfusion stage. No mortality due to cardiac-related events occurred among the patients during hospitalization. OLT with the modified piggyback technique could successfully be performed in ESLD patients with mild and moderate CAD.

CONCLUSIONS

A thorough evaluation and optimization of recipients, strict monitoring and optimized management of circulation, knowledge of the complicated changes during OLT procedures, and strategies to ameliorate post-reperfusion syndrome favorite the outcomes.

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.

Mind the Gap: Statin Underutilization and Impact on Mortality in Liver Transplant Recipients

Liver transplant (LT) recipients are at a substantially increased risk of cardiovascular disease compared due to accelerated development and progression of hypertension, diabetes, obesity and dyslipidemia. As a result, cardiovascular disease is a leading cause of morbidity and mortality post-LT. This is in spite of aggressive pre-transplant evaluation for prevalent cardiovascular disease, in particular coronary artery disease (CAD), and exclusion of very high-risk patients from LT. However the commonest causes of early (<1 year) cardiovascular disease complications are arrhythmias and heart failure, whereas coronary heart disease complications typically manifest later after LT.

Risk stratification of myocardial injury after liver transplantation in patients with computed tomographic coronary angiography-diagnosed coronary artery disease

We aimed to determine if the severity of computed tomographic coronary angiography (CTCA)-diagnosed coronary artery disease (CAD) is associated with postliver transplantation (LT) myocardial infarction (MI) within 30 days and early mortality. We retrospectively evaluated 2118 consecutive patients who underwent CAD screening using CTCA. Post-LT type-2 MI, elicited by oxygen supply-and-demand mismatch within a month after LT, was assessed according to the severity of CTCA-diagnosed CAD. Obstructive CAD (>50% narrowing, 9.2% prevalence) was identified in 21.7% of patients with 3 or more known CAD risk factors of the American Heart Association. Post-LT MI occurred in 60 (2.8%) of total patients in whom 90-day mortality rate was 16.7%. Rates of post-LT MI were 2.1%, 3.1%, 3.4%, 4.3%, and 21.4% for normal, nonobstructive CAD, and 1-, 2-, and 3-vessel obstructive CAD, respectively. Two-vessel or 3-vessel obstructive CAD showed a 4.9-fold higher post-LT MI risk compared to normal coronary vessels. The sensitivity and negative predictive value of obstructive CAD in detecting post-LT MI were, respectively, 20% and 97.5%. In conclusion, negative CTCA finding in suspected patients can successfully exclude post-LT MI, whereas proceeding with invasive angiography is needed to further risk-stratify in patients with significant CTCA-diagnosed CAD. Prognostic role of CTCA in predicting post-LT MI needs further research.

The relationship between coronary artery disease and cardiovascular events early after liver transplantation

BACKGROUND & AIMS

Cardiovascular complications are major contributors to mortality at liver transplantation (LT). However, the impact of coronary artery disease (CAD) on these complications is not well-understood as the literature is limited by non-invasive assessment of CAD, which is suboptimal in patients with cirrhosis. Thus, the current study evaluated cardiovascular events at LT stratified according to the presence and severity of CAD quantified on coronary angiography.

METHODS

All patients who had LT from January 2010 to January 2017 were evaluated (N = 348), but analysis was restricted to patients who had coronary angiography prior to LT (N = 283). Protocol coronary angiography was performed in all patients' ages >50 years, history of CAD, abnormal cardiac stress test or risk factors for CAD. The primary outcome was a cardiovascular composite outcome including myocardial infraction (MI), cardiac arrest, stroke, cardiac death, heart failure or arrhythmia occurring within 4 weeks after LT.

RESULTS

CAD was present in 92(32.5%) patients and 32(11.3%) had obstructive CAD. During the study period, 72(25.4%) patients met the primary cardiovascular outcome, the most common being arrhythmia (N = 59 or 20.8%). Non-ST elevation MI occurred in 11(3.9%) of patients. A total of 10 deaths (3.5%) occurred, of which 6(2.1%) were attributable to cardiac death. There was no evidence of a relationship between the presence and severity of CAD and composite cardiovascular events. In multiple regression modelling, only diabetes [OR 2.62, 95%CI (1.49, 4.64), P < 0.001] was associated with the likelihood of having a cardiovascular event.

CONCLUSION

Cardiovascular disease mortality is the most important contributor of early mortality after LT but is not related to the severity of CAD.

International Liver Transplantation Consensus Statement on End-stage Liver Disease Due to Nonalcoholic Steatohepatitis and Liver Transplantation

Nonalcoholic steatohepatitis (NASH)-related cirrhosis has become one of the most common indications for liver transplantation (LT), particularly in candidates older than 65 years. Typically, NASH candidates have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient evaluation and selection, waitlist morbidity and mortality, and eventually posttransplant outcomes. The purpose of these guidelines is to highlight specific features commonly observed in NASH candidates and strategies to optimize pretransplant evaluation and waitlist survival. More specifically, the working group addressed the following clinically relevant questions providing recommendations based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system supported by rigorous systematic reviews and consensus: (1) Is the outcome after LT similar to that of other etiologies of liver disease? (2) Is the natural history of NASH-related cirrhosis different from other etiologies of end-stage liver disease? (3) How should cardiovascular risk be assessed in the candidate for LT? Should the assessment differ from that done in other etiologies? (4) How should comorbidities (hypertension, diabetes, dyslipidemia, obesity, renal dysfunction, etc.) be treated in the candidate for LT? Should treatment and monitoring of these comorbidities differ from that applied in other etiologies? (5) What are the therapeutic strategies recommended to improve the cardiovascular and nutritional status of a NASH patient in the waiting list for LT? (6) Is there any circumstance where obesity should contraindicate LT? (7) What is the optimal time for bariatric surgery: before, during, or after LT? (8) How relevant is donor steatosis for LT in NASH patients?

Incidental Coronary Artery Calcification Seen on Low-Dose Computed Tomography Is a Risk Factor for Obstructive Coronary Artery Disease in Patients Undergoing Liver Transplant

Incidental arterial calcification (Ca) on low-dose computed tomography (CT) prior to liver transplant (LT) may help identify those at risk for obstructive coronary artery disease (CAD). A single-center retrospective study of 358 consecutive patients who had undergone LT was performed. Of the 296 patients who met inclusion criteria, 193 patients (65.2%) had CT Ca. Aortic Ca was seen in 116 (39.2%), coronary Ca in 141 (47.6%), and peripheral Ca in 8 patients (2.7%). Patients with coronary Ca were assigned ordinal coronary artery Ca scores and classified as mild, moderate, and severe. All-cause mortality was higher in patients with Ca in any location (14.5% vs 6.8%, P = .05). Of the patients who underwent coronary angiography, those with obstructive CAD were more likely to have aortic and coronary Ca than patients with nonobstructive or no CAD (85.7% vs 50.0%, P = .02 and 92.9% vs 37.9%, P = < .001, respectively). Severe coronary artery Ca scores were more frequent in patients with obstructive CAD (35.7% vs 0%, P < .001). Any severity coronary Ca had an odds ratio of 11.57 (95% CI, 1.61-244.92; P = .04) for obstructive CAD. In conclusion, incidental coronary Ca seen on low-dose CT is a risk factor for obstructive CAD in patients undergoing LT.

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.

Pretransplant coronary artery disease is a predictor for myocardial infarction and cardiac death after liver transplantation

BACKGROUND

Cardiovascular disease is a serious problem of liver transplant (LT) recipients because of increased cardiovascular risk due to immunosuppressive therapy, higher age, intraoperative risk and comorbidities (such as diabetes and nicotine abuse). Reported frequency of cardiovascular events after LT shows a high variability between different LT cohorts. Our aim was to analyze a cohort of LT recipients from a single center in Germany to evaluate frequency of the cardiovascular endpoints (CVE) myocardial infarction and/or cardiac death after LT and to investigate correlations of CVE post LT with pretransplant patient characteristics.

PATIENTS

In total, data from 352 LT patients were analyzed. Patients were identified from an administrative transplant database, and all data were retrieved from patients' charts and reports.

RESULTS

During the median follow-up of 4.0 (0-13) years, 10 cases of CVE were documented (six myocardial infarctions and four coronary deaths). The frequency of CVE did not differ according to classic cardiovascular risk factors such as body mass index (p=0.071), total cholesterol (p=0.533), hypertension (p=0.747), smoking (p=1.000) and pretransplant diabetes mellitus (p=0.146). In patients with pretransplant coronary heart disease (n=24; 6.8%) CVE were found more frequently (p=0.024).

CONCLUSION

In summary, we found a rate of 2.8% CVE after LT in a German transplant cohort. Pretransplant CHD was the only risk factor for CVE, but showed no significant impact on overall survival.

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.