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Gananandan K, Wiese S, Møller S, Mookerjee RP. Cardiac dysfunction in patients with cirrhosis and acute decompensation. Liver Int 2024; 44:1832-1841. [PMID: 38712826 DOI: 10.1111/liv.15896] [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: 01/22/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
The prevalence of cirrhotic cardiomyopathy (CCM) has been reported as high as 60%-70% in patients with liver cirrhosis and is associated with various negative outcomes. There has been a growing understanding of CCM over recent years. Indeed, the development of imaging techniques has enabled new diagnostic criteria to be proposed by the Cirrhotic Cardiomyopathy Consortium. However, important unanswered questions remain over pathophysiological mechanisms, optimal diagnostic modalities and potential treatment options. While there has been an increasing volume of literature evaluating CCM, there is a lack of clarity on its implications in acute decompensation, acute-on-chronic liver failure and following interventions such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. This review aims to summarise the literature in these challenging domains and suggest where future research should focus. We conclude that systemic inflammation and structural myocardial changes are likely to be crucial in the pathophysiology of the disease, but the relative contribution of different components remains elusive. Furthermore, future studies need to use standardised diagnostic criteria for CCM as well as incorporate newer imaging techniques assessing both myocardial structure and function. Finally, while specific treatments are currently lacking, therapeutics targeting systemic inflammation, microbial dysbiosis and bacterial translocation are promising targets and warrant further research.
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Affiliation(s)
- Kohilan Gananandan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Signe Wiese
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Gastroenterology Unit, Medical Division, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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ZHANG PF, TIAN JW, ZHU TG, WU JF, LENG XP, WANG Y, LI MM, LI XH, WANG QQ, FENG XP, LV JY, YIN LX, ZHANG Y, ZHANG M. Stress Echocardiography for Chronic Coronary Syndrome: Clinical Practice Guidelines (2023). J Geriatr Cardiol 2024; 21:475-505. [PMID: 38948890 PMCID: PMC11211908 DOI: 10.26599/1671-5411.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Affiliation(s)
- Peng-Fei ZHANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Jia-Wei TIAN
- The Second Affiliated Hospital of Harbin Medical University, Haerbin, China
| | | | - Jue-Fei WU
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao-Ping LENG
- The Second Affiliated Hospital of Harbin Medical University, Haerbin, China
| | - Yi WANG
- Sichuan Province People's Hospital, Chengdu, China
| | - Meng-Meng LI
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Xin-Hao LI
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qian-Qian WANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiao-Peng FENG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Jia-Yan LV
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Li-Xue YIN
- Sichuan Province People's Hospital, Chengdu, China
| | - Yun ZHANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Mei ZHANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
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Kleb C, Sims OT, Fares M, Ruthmann N, Ansari K, Esfeh JM. Screening Modalities for Coronary Artery Disease in Liver Transplant Candidates: A Review of the Literature. J Cardiothorac Vasc Anesth 2023; 37:2611-2620. [PMID: 37690949 DOI: 10.1053/j.jvca.2023.08.126] [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: 05/21/2023] [Revised: 07/16/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023]
Abstract
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.
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Affiliation(s)
- Cerise Kleb
- Department of Gastroenterology, University of Maryland Medical Center, Baltimore, MD.
| | - Omar T Sims
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Maan Fares
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Nicholas Ruthmann
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Kianoush Ansari
- Department of Diagnostic Radiology, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH
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Kassab K, Doukky R. Cardiac imaging for the assessment of patients being evaluated for liver transplantation. J Nucl Cardiol 2022; 29:1078-1090. [PMID: 33825142 DOI: 10.1007/s12350-021-02591-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
Cardiac risk assessment prior to liver transplantation has become widely accepted. With the emergence of nonalcoholic steatohepatitis among the leading causes of end-stage liver disease and the steady rise of the age of liver transplant recipients, the burden of cardiovascular diseases has markedly increased in this population. Selecting appropriate liver transplant candidates is crucial due to the increasing demand for scarce donor organs. The use of noninvasive cardiac imaging for pre-operative assessment of the cardiovascular status of liver transplant recipients has been on the rise, yet the optimal assessment strategy remains an area of active debate. In this review, we examine the relevant literature pertaining to the diagnostic and prognostic applications of noninvasive cardiac imaging in this population. We also propose a simple literature-based evaluation algorithm for CAD surveillance in liver transplant candidates.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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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.
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Echocardiography in the Liver Transplant Patient. Curr Cardiol Rep 2021; 23:110. [PMID: 34216273 DOI: 10.1007/s11886-021-01531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to review current echocardiographic modalities utilized in the assessment of the preoperative liver transplant candidate with an emphasis on newer techniques. We sought to assess if newer methods imparted additional diagnostic or prognostic accuracy compared to prior methods based on existing studies. RECENT FINDINGS Standard dobutamine stress echocardiography offers important information regarding operative risk and post-operative survival in liver transplant candidates; however, technologies such as speckle-tracking echocardiography (STE) and evaluation of diastolic function have emerged as useful tools as well. 2D-STE and diastolic echocardiography offer additional parameters such as global longitudinal strain and measures of diastolic dysfunction that can better predict peri-operative and post-operative complications in liver transplant candidates. If able, practitioners should utilize these methods routinely in their assessment of liver transplant candidates.
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Tiwari N, Margapuri J, Katamreddy A, Jubbal S, Madan N. Diagnostic accuracy of cardiac testing for coronary artery disease in potential liver transplant recipients: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 32:100714. [PMID: 33521238 PMCID: PMC7820133 DOI: 10.1016/j.ijcha.2021.100714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022]
Abstract
Background The incidence of coronary artery disease (CAD) in Liver transplant (LT) patients is much higher than prior estimates and the morbidity and mortality are significant in this group of patients. Coronary angiography is the gold standard for detection of CAD, a non-invasive test that allows appropriate risk stratification would be preferred. In this systematic review and meta-analysis, we sought to assess the pooled diagnostic accuracy of various noninvasive cardiac imaging tests in detecting CAD in patients listed for LT. Methods We performed a systematic review and meta-analysis of studies comparing sensitivity and specificity of non-invasive tests to that of coronary angiography in diagnosing coronary artery disease in patients undergoing liver transplantation. Results Five studies (616 participants) evaluated myocardial perfusion imaging (MPI); five studies (1243 participants) dobutamine stress echocardiography (DSE); and three (87 participants), other tests. MPI had a pooled sensitivity of 0.62 (95% CI 0.37, 0.83), specificity of 0.60 (95% CI 0.39, 0.79), diagnostic odds ratio (DOR) of 2.5 (95% CI 1.7, 5.64) and Area under the curve (AUC) 0.649. DSE had a pooled sensitivity of 0.25 (95%CI 0.09, 0.51), specificity of 0.68 (95% CI 0.44, 0.84) and DOR of 0.7 (95% CI 0.12, 3.84). Conclusions Our results show that both MPI and DSE are not effective screening tools for detecting CAD in patients with end-stage liver disease (ESLD). Future studies are needed to evaluate the role of real-time myocardial contrast echocardiography (RTMCE) and coronary artery calcium score (CAC) with coronary CT angiography in patients with ESLD.
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Affiliation(s)
- Nidhish Tiwari
- Jacobi Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Adarsh Katamreddy
- Jacobi Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sandeep Jubbal
- University of Massachusetts Medical School, Worcester, MA, USA
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Bonou M, Mavrogeni S, Kapelios CJ, Skouloudi M, Aggeli C, Cholongitas E, Papatheodoridis G, Barbetseas J. Preoperative Evaluation of Coronary Artery Disease in Liver Transplant Candidates: Many Unanswered Questions in Clinical Practice. Diagnostics (Basel) 2021; 11:diagnostics11010075. [PMID: 33466478 PMCID: PMC7824885 DOI: 10.3390/diagnostics11010075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular (CV) complications represent the first non-graft-related cause of death and the third overall cause of death among patients undergoing liver transplantation (LT). History of coronary artery disease is related to increased CV mortality following LT. Although it is of paramount importance to stratify CV risk in pre-LT patients, there is no consensus regarding the choice of the optimal non-invasive cardiac imaging test. Algorithms proposed by scientific associations include non-traditional risk factors, which are associated with increased cardiac risk profiles. Thus, an individualized pre-LT evaluation protocol should be followed. As the average age of patients undergoing LT and the number of candidates continue to rise, the “3 W” questions still remain unanswered, Who, Which and When? Who should be screened for coronary artery disease (CAD), which screening modality should be used and when should the asymptomatic waitlisted patients repeat cardiac evaluation? Prospective studies with large sample sizes are warranted to define an algorithm that can provide better risk stratification and more reliable survival prediction.
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Affiliation(s)
- Maria Bonou
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
| | - Sophie Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, 17674 Athens, Greece;
| | - Chris J. Kapelios
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
- Correspondence: or ; Tel.: +30-213-2061032; Fax: +30-213-2061761
| | - Marina Skouloudi
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
| | - Constantina Aggeli
- First Department of Cardiology, Hippokration General Hospital, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - George Papatheodoridis
- Department of Gastroenterology, Laiko General Hospital, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - John Barbetseas
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
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Buggs J, Aslam S, Walker C, Hook M, M. Matyja T, Rogers E, Nyce S, Patiño D, Kumar A, Kemmer N. Pre-Liver Transplant Coronary Artery Disease Workup for Low-Risk Patients. Am Surg 2020; 86:976-980. [DOI: 10.1177/0003134820942169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Coronary artery disease (CAD) is a leading cause of mortality following orthotopic liver transplant, yet there is no standardized protocol for pre-liver-transplant coronary artery disease assessment. The main objective of this study was to determine the agreement between 2 methods of cardiac risk assessment: dobutamine stress echocardiogram (DSE) and coronary calcium score (CCS) and to determine which test was best able to predict coronary calcification in low-risk patients. Methods A retrospective study was performed using the medical records of 436 patients who received cardiac clearance for a liver transplant. A total of 152 patients’ medical records were included based on the inclusion of patients who had received both DSE and CCS. A kappa coefficient was calculated to determine the agreement between the DSE and CCS results. In addition, the positive predictive values (PPVs) of both the CCS and DSE along with cardiac catheterization indicating abdominal occlusion were analyzed to compare the accuracy of the 2 tests. Results It was determined that there was a 12% agreement between DSE results and CCS. It was found that the DSE had a PPV of 56% and the CCS had a PPV of 80%. Conclusion From this data, it was concluded that there was no agreement between the results of the CCS and the DSE. While neither the CCS nor the DSE presents an optimal method of risk assessment, the CCS had a much higher PPV and was therefore determined to be the more accurate test.
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Affiliation(s)
- Jacentha Buggs
- Department of Transplant Surgery, Tampa General Medical Group, Tampa, FL, USA
| | - Sadaf Aslam
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Chelsea Walker
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Madison Hook
- Pre-medical Studies, University of Tampa, Tampa, FL, USA
| | | | - Ebonie Rogers
- Office of Clinical Research, Tampa General Hospital, Tampa, FL, USA
| | - Samantha Nyce
- Pre-medical Studies, University of Tampa, Tampa, FL, USA
| | - Diego Patiño
- Pre-medical Studies, University of Tampa, Tampa, FL, USA
| | - Ambuj Kumar
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Nyingi Kemmer
- Department of Transplant Hepatology, Tampa General Medical Group, Tampa, FL, USA
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Dimitroglou Y, Aggeli C, Alexopoulou A, Mavrogeni S, Tousoulis D. Cardiac Imaging in Liver Transplantation Candidates: Current Knowledge and Future Perspectives. J Clin Med 2019; 8:E2132. [PMID: 31817014 PMCID: PMC6947158 DOI: 10.3390/jcm8122132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular dysfunction in cirrhotic patients is a recognized clinical entity commonly referred to as cirrhotic cardiomyopathy. Systematic inflammation, autonomic dysfunction, and activation of vasodilatory factors lead to hyperdynamic circulation with high cardiac output and low peripheral vascular resistance. Counter acting mechanisms as well as direct effects on cardiac cells led to systolic or diastolic dysfunction and electromechanical abnormalities, which are usually masked at rest but exposed at stress situations. While cardiovascular complications and mortality are common in patients undergoing liver transplantation, they cannot be adequately predicted by conventional cardiac examination including transthoracic echocardiography. Newer echocardiography indices and other imaging modalities such as cardiac magnetic resonance have shown increased diagnostic accuracy with predictive implications in cardiovascular diseases. The scope of this review was to describe the role of cardiac imaging in the preoperative assessment of liver transplantation candidates with comprehensive analysis of the future perspectives anticipated by the use of newer echocardiography indices and cardiac magnetic resonance applications.
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Affiliation(s)
- Yannis Dimitroglou
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.)
| | - Constantina Aggeli
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.)
| | - Alexandra Alexopoulou
- Department of Internal Medicine and Research Laboratory, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece
| | - Sophie Mavrogeni
- Onassis Cardiac Center and National and Kapodistrian University of Athens, 176 74 Athens, Greece;
| | - Dimitris Tousoulis
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.)
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International Liver Transplantation Consensus Statement on End-stage Liver Disease Due to Nonalcoholic Steatohepatitis and Liver Transplantation. Transplantation 2019; 103:45-56. [PMID: 30153225 DOI: 10.1097/tp.0000000000002433] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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?
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Snipelisky D, Shipman J, Olson N, Pellikka P, Aqel B, McCully R, Watt K. Low to Intermediate Dose Atropine Administration During Dobutamine Stress Echocardiography in the Pre-Liver Transplant Population. Prog Transplant 2018; 28:361-367. [PMID: 30222085 DOI: 10.1177/1526924818800048] [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: 11/15/2022]
Abstract
INTRODUCTION Dobutamine stress echocardiography (DSE) is frequently used to screen for obstructive coronary artery disease in the pre-liver transplant evaluation. Although atropine is a commonly used adjunctive medication, no study has evaluated its side effect profile in patients with end-stage liver disease (ESLD). RESEARCH QUESTION What is the safety of atropine in candidates undergoing pre-liver transplant evaluation when atropine is used in stress testing? DESIGN This multicenter, prospective study enrolled patients over a 6-month period undergoing pre-liver transplant evaluation. Each patient completed a questionnaire assessing anticholinergic-related symptoms within 24 hours of testing and 48 hours following. Comparisons were made among patients receiving any atropine dose versus those who did not and among patients receiving at least 1 mg atropine and those receiving less/none. RESULTS Forty patients were evaluated, and 32 (80%) had adjunctive atropine administered. No differences in clinical characteristics were noted. In comparisons among patients receiving any dose of atropine with those who did not, questionnaire results indicated a higher rate of nausea prior to testing and higher overall symptom severity following testing in patients not receiving atropine. In comparisons among patients receiving less than 1 mg atropine with those receiving at least 1 mg atropine, no difference in pre- or posttesting questionnaire responses was present. No patient in the study required reversal agents or hospitalization within 7 days of testing. CONCLUSIONS Atropine, a hepatically metabolized medication, did not predispose patients with ESLD to an increased symptom burden, and clinical outcomes related to DSE were unaffected.
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Affiliation(s)
- David Snipelisky
- 1 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Justin Shipman
- 2 Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Nicole Olson
- 3 Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Patricia Pellikka
- 1 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Bashar Aqel
- 4 Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Robert McCully
- 1 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Kymberly Watt
- 5 Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Porter TR, Mulvagh SL, Abdelmoneim SS, Becher H, Belcik JT, Bierig M, Choy J, Gaibazzi N, Gillam LD, Janardhanan R, Kutty S, Leong-Poi H, Lindner JR, Main ML, Mathias W, Park MM, Senior R, Villanueva F. Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography: 2018 American Society of Echocardiography Guidelines Update. J Am Soc Echocardiogr 2018; 31:241-274. [DOI: 10.1016/j.echo.2017.11.013] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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