Clinical Utility of a Risk‐Adapted Protocol for the Evaluation of Coronary Artery Disease in Liver Transplant Recipients

Abstract

The prevalence and management of coronary artery disease (CAD) in liver transplantation (LT) candidates are not well characterized. The aims of this study were to evaluate the impact on clinical outcomes of a specifically designed protocol for the management of asymptomatic CAD in LT candidates and to investigate noninvasive risk profiles for obstructive and nonobstructive CAD for 202 LT candidates. Those with high baseline cardiovascular risk (CVR; defined by the presence of classic CVR factors and/or decreased ejection fraction) received coronary angiography and significant arterial stenosis and were treated with percutaneous stents. Patients were followed up after LT until death or coronary event (CE). There were 78 patients who received coronary evaluation (62 direct angiography, 14 computed tomography coronary angiography, and 2 both). Of them, 39 (50%) patients had CAD of any severity, and 6 (7.7%) had significant lesions (5 were amenable to be treated with stents, whereas 1 patient had diffuse lesions which contraindicated the LT). Insulin‐dependent diabetes was the only factor related to CAD of any severity (odds ratio, 3.44; 95% confidence interval [CI], 1.00‐11.97). A total of 69 patients (46 with coronary evaluation) received LT. The incidence of CEs and overall survival after LT were similar between patients with and without coronary evaluation. Furthermore, no differences occurred between these groups in a multivariate competing risk model (subhazard ratio, 0.84; 95% CI, 0.27‐2.61; P = 0.76). In conclusion, the application of an angiographic screening protocol of CAD in a selected high‐risk Mediterranean population is safe and effective. The short‐ and medium‐term incidence rates of CEs and death after LT in this population are similar to that observed in low‐risk patients.

Intraoperative Troponin Elevation in Liver Transplantation Is Independently Associated With Mortality: A Prospective Observational Study

“…All patients who received elective LT underwent standardized preoperative assessment, including blood analysis, chest X‐ray, electrocardiogram (ECG), pulmonary functional testing, and cardiac ultrasonography. Direct coronary imaging via computed tomography (CT) scan or direct cardiac catheterization was also obtained according to the cardiovascular recipients’ risk factors …”

NAFLD and liver transplantation: Disease burden, current management and future challenges

“…89,90 However, non-invasive functional testing has limited predictive value for obstructive coronary artery disease in patients with cirrhosis, in whom the sensitivity and specificity of dobutamine stress echocardiography are reduced. 91,92 Although coronary angiography is considered the gold standard, studies performed in LT candidates are not completely conclusive, 93,94 making it difficult to predict the real impact of pre-LT asymptomatic cardiovascular abnormalities on long-term outcomes. However, a recent study has shown that pretransplant coronary artery disease, when adequately treated, may not affect post-LT survival.…”

Acute heart failure after liver transplantation: A narrative review

“…[42][43][44] The recent development of an angiographic screening protocol for LT candidates with high baseline cardiovascular risk may be a step in the right direction but needs further validation in larger and more diverse population cohorts. 45 Performing coronary angiography in this patient population carries higher risk of procedural complications due to high incidence of clotting disorders and renal insufficiency. 41 In addition, percutaneous coronary intervention or coronary artery bypass grafting before LT has not been shown to impart cardiovascular survival benefit.…”

“…However, DSE does not accurately reflect the severity of obstructive CAD in liver transplant candidates and despite various advances in knowledge, no gold standard has yet been developed for cardiac evaluation in LT candidates 42‐44 . The recent development of an angiographic screening protocol for LT candidates with high baseline cardiovascular risk may be a step in the right direction but needs further validation in larger and more diverse population cohorts 45 . Performing coronary angiography in this patient population carries higher risk of procedural complications due to high incidence of clotting disorders and renal insufficiency 41 .…”