Cardiac risk stratification of the liver transplant candidate: A comprehensive review

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.

CACS, CCTA and mCAD‐LT score in the pre‐transplant assessment of coronary artery disease and the prediction of post‐transplant cardiovascular events

“…Computed tomography (CT)‐related techniques, both coronary artery calcium score (CACS) and coronary CT angiography (CCTA), are being increasingly used in the general population to assess the presence and severity of CAD, and they may be a reliable screening option for preoperative non‐invasive evaluation of CAD in LT candidates 12–16 . Recent expert reviews 10,17 and, more importantly, an AHA scientific statement endorsed by the AST 18 recommend these techniques to evaluate the presence of CAD before LT, and at the same time highlight the need to collect more information regarding their diagnostic and prognostic yield in large, well‐characterized cohorts.…”

“…option for preoperative non-invasive evaluation of CAD in LT candidates. [12][13][14][15][16] Recent expert reviews 10,17 and, more importantly, an AHA scientific statement endorsed by the AST 18 recommend these techniques to evaluate the presence of CAD before LT, and at the same time highlight the need to collect more information regarding their diagnostic and prognostic yield in large, well-characterized cohorts.…”

Anesthetic Considerations for Patients With Mitral Stenosis Undergoing Orthotopic Liver Transplant

“…Mitral stenosis increases morbidity and mortality during the peri-and post-operative periods [1]. Mitral stenosis results in increased resistance to left ventricular filling and subsequent deleterious effects including pulmonary congestion, increased pulmonary vascular resistance, increased right ventricular wall tension, and hepatic congestion [2,3].…”