Coronary artery disease in orthotopic liver transplantation: Pretransplant assessment and management

Abstract

The prevalence of coronary artery disease in end-stage liver disease is only now being recognized. Liver transplant patients are a high risk subgroup for coronary artery disease, even if asymptomatic. Coronary artery disease is a predictor of poor outcomes; therefore, identification of those at risk must be a key clinical priority. However, risk assessment is particularly difficult as many of the available diagnostic tools have either proven to be unhelpful or remain to be validated. Risk factor profiling has been unable to identify those at risk and commonly underestimates risk. The high negative predictive value of Dobutamine stress echo, when target heart rates are achieved, allows it to be used to identify a low risk group. For all other patients, proceeding to invasive coronary angiography is often necessary, and the risks of the procedure can be reduced by a transradial approach. Pharmacological reduction of the consequences of coronary artery disease can be limited by the underlying liver disease. Revascularization pre-transplantation is recommended in international guidelines but has demonstrated little evidence of benefit. Surgical revascularization carries an increased risk in these patients and is commonly performed pre-transplantation, although combined liver and cardiac surgery has been described. Percutaneous coronary intervention is increasingly used with patients requiring anti-platelet medication for up to one year after intervention. We present a review of all these issues and the evidence for assessing and managing these high-risk patients. Liver Transpl 16:550-557,

Liver Transplantation Outcome in Patients With Angiographically Proven Coronary Artery Disease: A Multi-Institutional Study

“…The mean MELD ranged from 21 to 26 and was highest in the CAD(−) group and lowest in the CADsev group. For all groups, the mean MELD (SD) was 22 (8). There were more male patients in the CADmod (86%) and CADsev (78%) groups compared to the CAD(−) group (67%).…”

“…Despite the increased prevalence of CAD in LT candidates, there are few studies that have characterized the effect of CAD severity and treatment on the outcome of LT patients (4)(5)(6)(7). Due to the aging of patients with end-stage liver disease (ESLD), an increasing number of older patients on LT waitlists, and limited organ resources, coronary angiography is increasingly advocated to evaluate LT candidates (8)(9)(10) Angiography is often employed in place of noninvasive testing in the evaluation of older and higher risk candidates, as noninvasive tests for myocardial ischemia have varying degrees of reliability in LT candidates (5,(11)(12)(13)(14)(15). To date, no multicenter study has investigated the post-LT survival of patients with angiographically proven obstructive CAD.…”

Role of cardiac catheterization and percutaneous coronary intervention in the preoperative assessment and management of patients before orthotopic liver transplantation

“…Indeed, 2 recent reviews suggested that dedicated cardiologists should risk-stratify these patients and that a lower threshold for angiography should be considered for patients presenting for OLT because of the physiological state of cirrhosis, although again, overall consensus is lacking. 19,20 These considerations raise the question of how best to minimize such CV events. Prior guidelines and the practice during period A in this study followed traditional cardiac evaluation methods, with stress testing as the primary assessment of risk for noncardiac surgery.…”

Cardiopulmonary Disease in the Liver Transplant Patient: The Role of Doppler Echocardiography

“…End-stage liver disease is associated with increased risk of coronary artery disease. (Ehtisham, 2010). The incidence of coronary artery disease in liver transplant candidates over the age of 50 years has been reported as high as 28%.…”