1
|
Martinez-Perez S, McCluskey SA, Davierwala PM, Kalra S, Nguyen E, Bhat M, Borosz C, Luzzi C, Jaeckel E, Neethling E. Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions. J Cardiothorac Vasc Anesth 2024; 38:1015-1030. [PMID: 38185566 DOI: 10.1053/j.jvca.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024]
Abstract
Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.
Collapse
Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre Toronto, General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sanjog Kalra
- Division of Cardiology, Interventional Cardiology Section, Peter Munk Cardiac Center Toronto General Hospital, University Health Network and Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elsie Nguyen
- Department of Medical Imaging, Cardiothoracic Imaging Division Lead, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Gastroenterology, Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Borosz
- Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Carla Luzzi
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Department of Gastroenterology, Ajmera Transplant Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Elmari Neethling
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
Chong HJ, Jang MK, Kim HK. Cardiovascular risk trajectory and its associated factors among candidates on the waiting list for deceased-donor kidney transplantation: A longitudinal study. Heart Lung 2024; 63:114-118. [PMID: 37871518 DOI: 10.1016/j.hrtlng.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/30/2023] [Accepted: 10/15/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Cardiovascular disease is a significant cause of morbidity and mortality for wait-listed kidney transplant candidates. Since cardiovascular risk is related to a variety of factors and may change with time, longitudinal changes in cardiovascular risk and related factors in candidates need to be investigated. OBJECTIVES This study aimed to examine the trajectory of the cardiovascular risk score and its related factors in patients on the waiting list for deceased-donor kidney transplantation (DDKT). METHODS This longitudinal study enrolled 144 patients who were registered as candidates for a DDKT at a transplant center in South Korea. During the 5-year follow-up period, 3 candidates on the waiting list were transferred to other hospitals, 19 candidates died, and 31 candidates received kidney transplantation. RESULTS Approximately 26.6 % of the candidates had a high level of cardiovascular risk, and this increased to 53.2 % after 5 years. A high risk of psychosocial status (β=0.351, p=.026) was the most significant predictor of cardiovascular risk, followed by higher comorbidity (β=0.263, p<.001). Comorbidities were a significant factor associated with cardiovascular risk throughout the 5-year period, whereas the duration of dialysis and waiting time were significant only within 1 year after baseline. CONCLUSION Cardiovascular risk during 5 years on the waiting list for DDKT was associated with multidimensional factors, including psychosocial status before transplantation, comorbidity, waiting time for transplantation, and the duration of dialysis. In addition to managing comorbid conditions, shortening the waiting time and duration of dialysis is important for reducing cardiovascular risk during the long-term care of candidates on the waiting list for DDKT.
Collapse
Affiliation(s)
- Hye Jin Chong
- Department of Nursing, Sunchon National University, Jeolanam-do, Republic of Korea; Research Institute of Nursing Science, Jeonbuk National University, Jeonju, Republic of Korea
| | - Min Kyeong Jang
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, Republic of Korea
| | - Hyun Kyung Kim
- Research Institute of Nursing Science, Jeonbuk National University, Jeonju, Republic of Korea; College of Nursing, Jeonbuk National University, Jeonju, Republic of Korea.
| |
Collapse
|
3
|
De Gasperi A, Petrò L, Cerutti E. Liver Transplantation and the Elderly Candidate: Perioperative Considerations. Anesthesiol Clin 2023; 41:595-611. [PMID: 37516497 DOI: 10.1016/j.anclin.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Pioneered by Thomas Starzl in the early 1970s, liver transplant (LT) is nowadays often considered a final intervention and standard of care to cure many forms of acute and chronic end-stage liver diseases. Started in recipients younger than 60 years old, LT indications are now much broader, and at least, one-fifth of the candidates are older than 65 years. Problems associated with ageing and frailty in LT recipients and their impact on the entire perioperative course are discussed according to a modern anesthesiological perspective and the anesthesiologist covering the role of the perioperative (transplant) physician.
Collapse
Affiliation(s)
| | - Laura Petrò
- ANRI1 - Emergency and Intensive Care, ASST Ospedale Giovanni XXIII, Bergamo, Italy; ASST Papa Giovanni XXII, Piazza MSO 1, 24100 Bergamo, Italy
| | - Elisabetta Cerutti
- Anestesia e Rianimazione dei Trapianti e Chirurgia Maggiore, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60020, Ancona, Italy; Azienda Ospedaliero Universitaria "Ospedali Riuniti", Via Conca 71, 60020, Ancona, Italy
| |
Collapse
|
4
|
Steinmetz T, Perl L, Zvi BR, Atamna M, Kornowski R, Shiyovich A, Hamdan A, Nesher E, Rahamimov R, Gal TB, Skalsky K. The prognostic value of pre-operative coronary evaluation in kidney transplanted patients. Front Cardiovasc Med 2022; 9:974158. [PMID: 35990935 PMCID: PMC9389011 DOI: 10.3389/fcvm.2022.974158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Aims Non-invasive coronary assessment using single-photon emission computerized tomography (SPECT) testing for potential cardiac ischemia is an essential part of the evaluation of kidney transplant candidates. We aimed to examine the prognostic value of preoperative SPECT test results in kidney transplanted patients. Methods and results We retrospectively analyzed the pre-surgical nuclear SPECT test results in a registry of kidney transplanted patients. Follow-up at 1 month and 1 year recorded major adverse cardiac events (MACE) including non-fatal myocardial infarction, all-cause mortality and hospitalization due to cardiovascular disease following the renal transplantation. Of 577 patients available for analysis, 408 (70.9%) patients underwent nuclear SPECT test pre-transplant and 83 (20.3%) had abnormal results with either evidence of ischemia or infarct. A significantly higher incidence of post-operative MACE at 1 month was evident among patients with abnormal SPECT test compared to patients with no evidence of ischemia (10.8 vs. 4.3% respectively; P = 0.019). Differences were mostly derived from significantly increased rates of myocardial infarction events (8.4 vs. 1.8%; P = 0.002). Yet, MACE rate was not statistically different at 1 year (20.5 vs. 13.1%; P = 0.88). Importantly, the prognostic impact of an abnormal SPECT was significantly attenuated for all outcomes following multivariable adjusting for conventional cardiovascular risk factors and coronary revascularization. Conclusion Pre-surgical cardiac risk assessment of kidney transplant candidates with nuclear SPECT test was found to be predictive of post-operative MACE, yet apparently, its prognostic value was significantly attenuated when adjusted for cardiac risk factors.
Collapse
Affiliation(s)
- Tali Steinmetz
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Benaya Rozen Zvi
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohamad Atamna
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur Shiyovich
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Ashraf Hamdan
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Eviatar Nesher
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Transplantation, Rabin Medical Center, Petach-Tikva, Israel
| | - Ruth Rahamimov
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tuvia Ben Gal
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Keren Skalsky
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
- *Correspondence: Keren Skalsky
| |
Collapse
|
5
|
Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, Contreras-Yametti FI, Murthy S, Jorde UP. Cardiac risk stratification of the liver transplant candidate: A comprehensive review. World J Transplant 2022; 12:142-156. [PMID: 36051452 PMCID: PMC9331410 DOI: 10.5500/wjt.v12.i7.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
Collapse
Affiliation(s)
- Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
| | - Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
| | | | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| |
Collapse
|
6
|
Sandal S, Ahn JB, Segev DL, Cantarovich M, McAdams-DeMarco MA. Comparing outcomes of third and fourth kidney transplantation in older and younger patients. Am J Transplant 2021; 21:4023-4031. [PMID: 34355512 PMCID: PMC8639643 DOI: 10.1111/ajt.16786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 01/25/2023]
Abstract
Performing third or fourth kidney transplantation (3KT and 4KT) in older patients is rare due to surgical and immunologic challenges. We aimed to analyze and compare the outcomes of younger (18-64 years) and older (≥65 years) recipients of 3KT and 4KT. Between 1990 and 2016, we identified 5816 recipients of 3KTs (153 were older) and 886 recipients of 4KTs (18 were older). The incidences of delayed graft function (24.3% vs. 24.8%, p = .89), primary non-function (3.2% vs. 1.3%, p = .21), 1-year acute rejection (18.6% vs. 14.8%, p = .24), and 5-year death censored graft failure (DCGF) (24.8% vs. 17.9%, p = .06) were not different between younger and older recipients of 3KT. However, 5-year mortality was higher in older recipients (14.0% vs. 33.8%, p < .001) which remained significant after adjustment (aHR = 3.21, 95% CI: 2.59-3.99). Similar patterns were noted in the 4KT cohort. When compared with waitlisted patients, 3KT and 4KT are associated with a lower risk of mortality; aHR = 0.37, 95% CI: 0.33-0.41 and aHR = 0.31, 95% CI: 0.24-0.41, respectively. This survival benefit did not differ by recipient age (younger vs. older, p for interaction = 3KT: .49 and 4KT: .58). In the largest cohort described to date, we report that there is a survival benefit of 3KT and 4KT even among older patients. Although a highly selected cohort, our results support improving access to 3KT and 4KT.
Collapse
Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec,Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec,Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
7
|
Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans. J Clin Med 2021; 10:jcm10215148. [PMID: 34768667 PMCID: PMC8584855 DOI: 10.3390/jcm10215148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 12/04/2022] Open
Abstract
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.
Collapse
|
8
|
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is a serious complication of liver cirrhosis with poor survival in the absence of liver transplantation (LT). HRS represents a state of profound circulatory and cardiac dysfunction. Whether it increases risk of perioperative major adverse cardiovascular events (MACE) following LT remains unclear. METHODS We performed a retrospective cohort study of 560 consecutive patients undergoing cardiac workup for LT of whom 319 proceeded to LT. All patients underwent standardized assessment including dobutamine stress echocardiography. HRS was defined according to International Club of Ascites criteria. RESULTS Primary outcome of 30-day MACE occurred in 74 (23.2%) patients. A significantly higher proportion of patients with HRS experienced MACE (31 [41.9%] versus 54 [22.0%]; P = 0.001). After adjusting for age, model for end-stage liver disease score, cardiovascular risk index, history of coronary artery disease, and a positive stress test, HRS remained an independent predictor for MACE (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.13-5.78). Other independent predictors included poor functional status (OR, 3.38; 95% CI, 1.41-8.13), pulmonary hypertension (OR, 3.26; 95% CI, 1.17-5.56), and beta-blocker use (OR, 2.56; 95% CI, 1.10-6.48). Occurrence of perioperative MACE was associated with a trend toward poor age-adjusted survival over 3.6-year follow-up (hazard ratio, 2.0; 95% CI, 0.98-4.10; P = 0.057). CONCLUSIONS HRS, beta-blocker use, pulmonary hypertension, and poor functional status were all associated with over a 2-fold higher risk of MACE following LT. Whether inclusion of these variables in routine preoperative assessment can facilitate cardiac risk stratification warrants further study.
Collapse
|
9
|
Inducible Left Ventricular Outflow Tract Obstruction in Patients Undergoing Liver Transplantation: Prevalence, Predictors, and Association With Cardiovascular Events. Transplantation 2021; 105:354-362. [PMID: 32229775 DOI: 10.1097/tp.0000000000003245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inducible left ventricular outflow tract obstruction (LVOTO) is often encountered in liver transplantation (LT) candidates during cardiac workup. While the impact of LVOTO on adverse cardiovascular hemodynamics is well reported, it is unclear whether it predisposes to perioperative cardiovascular complications. METHODS Consecutive patients with end-stage liver disease undergoing dobutamine stress echocardiography (DSE) were evaluated at an LT center between 2010 and 2017. Perioperative major adverse cardiovascular events (MACEs) at 30 days and all-cause death were recorded from a prospectively maintained LT database. RESULTS We evaluated 560 patients who underwent DSE during LT workup, with LVOTO identified in 24.3% (n = 136). Of these, 309 patients progressed to transplant. Patients with LVOTO demonstrated a lower peak systolic blood pressure (SBP) and an overall reduction in SBP on DSE. A total of 85 MACEs were recorded in 72 patients (23.3%) including 3 deaths, 19 cases of heart failure, 11 cardiac arrests, 8 acute coronary syndromes, and 44 arrhythmias. MACE occurred in 15/64 patients (23.4%) with LVOTO and 57/245 (23.3%) without (P = 0.92). There was an increased risk of perioperative cardiac arrest in patients with LVOTO (7.4% versus 2.4%, P = 0.04). Intraoperatively, patients with LVOTO required higher doses of vasopressors (P = 0.01) and received greater volumes of fluid (10.5 ± 8.1 versus 8.4 ± 6.4 L, P = 0.03). CONCLUSIONS Patients with end-stage liver disease and LVOTO demonstrate a reduction in SBP during physiological stress that may translate to hemodynamic instability during LT. LVOTO was not associated with an increased rate of perioperative MACE or death.
Collapse
|
10
|
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.
Collapse
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.)
| |
Collapse
|
11
|
Hughes DL, Rice JD, Burton JR, Jin Y, Peterson RA, Ambardekar AV, Pomposelli JJ, Pomfret EA, Kriss MS. Presence of any degree of coronary artery disease among liver transplant candidates is associated with increased rate of post-transplant major adverse cardiac events. Clin Transplant 2020; 34:e14077. [PMID: 32939833 DOI: 10.1111/ctr.14077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/24/2020] [Accepted: 08/22/2020] [Indexed: 01/14/2023]
Abstract
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.
Collapse
Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan D Rice
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - James R Burton
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ying Jin
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan A Peterson
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amrut V Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - James J Pomposelli
- Division of Transplant Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael S Kriss
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|