Cardiac Risk Stratification in Liver Transplantation: Results of a Tiered Assessment Protocol Based on Traditional Cardiovascular Risk Factors

Abstract

Coronary artery disease (CAD) confers increased perioperative risk in patients undergoing liver transplantation (LT).Although routine screening for CAD is recommended, there are limited data on the effectiveness of screening strategies. We evaluated the safety and efficacy of a 3-tiered cardiac risk-assessment protocol that stratifies patients based on age and traditional cardiac risk factors. We peformed a single-center, prospective, observational study of consecutive adult patients undergoing LT assessment ( 2010-2017). Patients were stratified into low-risk (LR), intermediate-risk (IR), or high-risk (HR) cardiac groups and received standardized investigations with selective use of transthoracic echocardiography (TTE), dobutamine stress echocardiography (DSE), computed tomography coronary angiography (CTCA), and coronary angiography (CA). Primary outcomes were cardiac events (CEs) and cardiovascular death up to 30 days after LT. Overall, 569 patients were included, with 76 patients identified as LR, 256 as IR, and 237 as HR. Cardiac risk factors included diabetes mellitus (26.0%), smoking history (47.3%), hypertension (17.8%), hypercholesterolemia (7.2%), family (17.0%) or prior history of heart disease (6.0%), and obesity (27.6%). Of the patients, 42.0% had ≥2 risk factors. Overall compliance with the protocol was 90.3%. Abnormal findings on TTE, DSE, and CTCA were documented in 3, 23, and 44 patients, respectively, and 12 patients were not listed for transplantation following cardiac assessment (1 LR, 2 IR, and 9 HR). Moderate or severe CAD was identified in 25.4% of HR patients on CTCA following a normal DSE. CEs were recorded in 7 patients (1.2%), with 2 cardiovascular deaths (0.4%). Cardiac risk stratification based on traditional cardiac risk factors with the selective use of DSE, CTCA, and CA is a safe and feasible approach that results in a low perioperative cardiac event rate.

Acute coronary syndrome after liver transplantation in a young primary biliary cholangitis recipient with dyslipidemia: a case report

“…In particular, a patient with a long history of PBC and drug-resistant dyslipidemia would be a suitable candidate. According to a recent report, the selective use of dobutamine stress echocardiography, CCTA and coronary angiography would be a safe and feasible approach in LT recipients [ 27 ]. However, considering the medical cost and burden, widespread evaluation in low-risk patients is not realistic.…”

Cardiovascular events after liver transplantation: MACE hurts

“…Other risk factors for cardiovascular events after liver transplantation include smoking history (47.3%), obesity (27.6%), diabetes mellitus (26.0%), hypertension (17.8%), family history (17.0%) or prior history of heart disease (6.0%), and hypercholesterolemia (7.2%) [54]. Van Wagner and colleagues also revealed that the following factors are associated with MACE: age, ethnicity, health care status, hospitalization status, socioeconomic status, recipient functional status at transplant, MELD score, cause of ESLD, complications of ESLD at LT such as hepatic encephalopathy, spontaneous bacterial peritonitis, etc.…”

Moving Forward in the Stratification of Cardiac Risk in Liver Transplantation Candidates

“…In this issue of Liver Transplantation , Robertson et al ( 7 ) report the results of the cardiac assessment protocol for LT candidates set in the Victorian Liver Transplant Unit (Australia) in 2010. Having included 569 patients until 2017, it is one of the largest single‐center studies of its kind.…”

“…However, there is growing evidence showing the limitations of stress tests in patient with cirrhosis, (5) and new noninvasive cardiac imaging techniques, particularly coronary computed tomography angiography (CCTA) with calcium score, are being incorporated in clinical practice. Considering the worsening cardiovascular profile of our patients, the impact of cardiovascular disease on post-LT outcomes, and the limited experience with noninvasive and invasive coronary angiography (CA) in LT candidates, it is imperative for the LT community to be able to explore and compare the efficacy and safety of different protocols approaching the diagnosis of silent CAD before LT. (5) In this issue of Liver Transplantation, Robertson et al (7) report the results of the cardiac assessment protocol for LT candidates set in the Victorian Liver Transplant Unit (Australia) in 2010. Having included 569 patients until 2017, it is one of the largest single-center studies of its kind.…”