Adverse cardiac events after orthotopic liver transplantation: A cross‐sectional study in 389 consecutive patients

Abstract

Current American College of Cardiology/American Heart Association guidelines caution that preoperative noninvasive cardiac tests may have poor predictive value for detecting coronary artery disease in liver transplant candidates. The purpose of our study was to evaluate the role of clinical predictor variables for early and late cardiac morbidity and mortality and the predictive values of noninvasive cardiac tests for perioperative cardiac events in a high-risk liver transplant population. In all, 389 adult recipients were retrospectively analyzed for a median follow-up time of 3.4 years (range 5 2.3-4.4 years). Overall survival was 83%. During the first year after transplantation, cardiovascular morbidity and mortality rates were 15.2% and 2.8%. In patients who survived the first year, cardiovascular morbidity and mortality rates were 3.9% and 2%, with cardiovascular etiology as the third leading cause of death. Dobutamine stress echocardiography (DSE) and single-photon emission computed tomography had respective sensitivities of 9% and 57%, specificities of 98% and 75%, positive predictive values of 33% and 28%, and negative predictive values of 89% and 91% for predicting early cardiac events. A rate blood pressure product less than 12,000 with DSE was associated with an increased risk for postoperative atrial fibrillation. Correspondence analysis identified a statistical association between nonalcoholic steatohepatitis/cryptogenic cirrhosis and postoperative myocardial ischemia. Logistic regression identified 3 risk factors for postoperative acute coronary syndrome: age, history of coronary artery disease, and pretransplant requirement for vasopressors. Multivariable analysis showed statistical associations of the Model for End-Stage Liver Disease score and the development of acute kidney injury as risk factors for overall cardiac-related mortality. These findings may help in identifying high-risk patients and may lead to the development of better cardiac tests. Liver Transpl 21:13-21, 2015. V C 2014 AASLD.

Factors Associated With Major Adverse Cardiovascular Events After Liver Transplantation Among a National Sample

“…This is higher than the early MACE rate after other types of intraabdominal surgery ranging from 0.1% in laparoscopic cholecystectomy(23) to 0.2% after Whipple(24) and is in line with early MACE rates after kidney transplantation, historically the highest risk transplant population for MACE, which ranges from 3.3% to 13.4%(25, 26). The early MACE rate reported in the current study is consistent with previously published single-center studies that have reported MACE rates after LT ranging from 7% to 15%(2, 14, 18). To our knowledge we are the first to provide a multicenter estimate that may provide more accurate and precise data on the true prevalence of early MACE in the current era of transplantation.…”

Incidence of and Risk Assessment for Adverse Cardiovascular Outcomes After Liver Transplantation

“…In general, dobutamine stress echocardiography (DSE) remains a mainstay of first line cardiac testing in LT candidates, though the accuracy of this tool in appropriately identifying high risk patients is in doubt. 8,9 To date, there has not been a systematic summary of the existing literature on this topic. As such, it has been difficult for clinicians to understand the true scope of the burden of CV events post-LT, to identify which patients are at highest risk for these outcomes, and to then apply a high yield cardiac risk stratification approach to their individual patients.…”

Coronary Computed Tomography Angiography in Combination with Coronary Artery Calcium Scoring for the Preoperative Cardiac Evaluation of Liver Transplant Recipients

“…In a subset analysis of orthotopic liver transplant candidates, dobutamine stress echocardiography compared with coronary angiography has a 75% sensitivity and 57% specificity in detecting CAD [12]. Dobutamine stress echocardiography has a 9% sensitivity, 33% positive predictive value, and 89% negative predictive value for predicting early cardiac events after liver transplantation [13]. …”

“…Adenosine-SPECT has a sensitivity of 62% and a positive predictive value of 30% for diagnosing severe CAD in patients with end-stage liver disease [40]. In patients undergoing orthotopic liver transplantation, SPECT has a sensitivity of 57%, a positive predictive value of 28%, and a negative predictive value of 91% for predicting early cardiac events [13]. A primary deficiency of SPECT is associated with the vasodilating agents used (adenosine and dipyridamole).…”

“…The prevalence of CAD ranges between 2.5% and 12% in patients undergoing orthotopic liver transplantation [9–12]. The history of CAD is also reported to be an important risk factor for postoperative acute coronary syndrome in liver transplant recipients [13]. Taken together, the evidence to date indicates that meticulous cardiovascular evaluations are required to assess perioperative risks and to prevent concomitant cardiovascular complications that would preclude good outcomes in patients undergoing liver transplantation.…”