Cardiac Imaging in Liver Transplantation Candidates: Current Knowledge and Future Perspectives

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.

Speckle Tracking Analysis Reveals Altered Left Atrial and Ventricular Myocardial Deformation in Patients with End-Stage Liver Disease

“…Mild CCM usually remains asymptomatic at rest and most commonly manifests as prolonged QT interval ECG abnormality and sole diastolic dysfunction seen in 2D imaging [ 2 , 3 , 4 ]. Diagnosis of CCM is frequently missed or delayed due to its asymptomatic state and seemingly normal cardiac function at rest [ 2 , 4 , 5 , 6 ].…”

“…However, acute stress conditions, such as infection, transjugular intrahepatic portosystemic shunt (TIPS) procedure, or liver transplantation (LTx), can lead to extreme forms of CCM with overt heart failure in patients with end-stage liver disease (ESLD) [ 4 , 5 ]. Transthoracic echocardiography (TTE) is required by the European Association for the Study of the Liver to unmask previously unknown cardiological conditions [ 5 ].…”

“…However, acute stress conditions, such as infection, transjugular intrahepatic portosystemic shunt (TIPS) procedure, or liver transplantation (LTx), can lead to extreme forms of CCM with overt heart failure in patients with end-stage liver disease (ESLD) [ 4 , 5 ]. Transthoracic echocardiography (TTE) is required by the European Association for the Study of the Liver to unmask previously unknown cardiological conditions [ 5 ]. More elaborate evaluations (i.e., using dobutamine stress echocardiography) are usually only performed if abnormal TTE results were collected or if the patient’s profile presents certain risk factors [ 4 , 5 ].…”

“…Transthoracic echocardiography (TTE) is required by the European Association for the Study of the Liver to unmask previously unknown cardiological conditions [ 5 ]. More elaborate evaluations (i.e., using dobutamine stress echocardiography) are usually only performed if abnormal TTE results were collected or if the patient’s profile presents certain risk factors [ 4 , 5 ]. Estimates of ESLD patients who underwent LTx with an unknown cardiovascular disease are as high as 25–50% [ 2 , 3 , 4 , 5 , 6 ], and cardiovascular events account for approximately 7–21% of the subsequent deaths [ 5 , 7 ].…”

Preoperative Evaluation of Coronary Artery Disease in Liver Transplant Candidates: Many Unanswered Questions in Clinical Practice

“…CMR is an operator independent modality with high reproducibility [ 59 ]. CMR can provide a “one-stop-shop” approach to evaluate cardiac structure, function, and ischemia in LT candidates [ 60 , 61 ]. It can detect ischemia using two different ways: (a) by observing wall motion abnormalities, using the stress factor dobutamine, exhibiting better sensitivity and specificity than DSE and (b) by observing myocardial perfusion using the first pass of a bolus of a T1-shortening contrast agent (first-pass gadolinium) injected into a peripheral vein [ 62 , 63 ].…”