Living Donor Liver Transplantation Following Transcatheter Aortic Valve Implantation for Aortic Valvular Disease

Abstract

Over the last few decades, outcomes with living donor liver transplantation (LDLT) have improved significantly. This has resulted in patients who were denied liver transplantation previously, due to various comorbidities and high risk, now being considered for LDLT. This includes patients with severe valvular heart disease such as aortic stenosis. These patients require aortic valve replacement to help cope with significant perioperative hemodynamic changes. High-risk cardiac procedures like aortic valve replacement are associated with serious perioperative morbidity and mortality in patients with end-stage liver disease. Since the advent of transcatheter aortic valve implantation (TAVI) in 2002, there have been a few case reports of its successful use prior to deceased donor liver transplantation, but there is no literature on this procedure before LDLT. In this article, we report our experience with 2 patients, the first patient with infective endocarditis-induced acute aortic regurgitation and the second patient with bicuspid aortic stenosis who underwent uneventful TAVI followed by successful LDLT. In conclusion, with the increasing expertise and experience in this procedure, an increasing number of potential recipients, previously considered as high-risk transplant candidates, can now be offered liver transplantation by performing pretransplant TAVI.

Transcatheter aortic valve replacement (TAVR) as bridge therapy restoring eligibility for liver transplantation in cirrhotic patients

“…[8][9][10][11] History of cirrhosis or liver disease is frequently an exclusion criterion for randomized controlled trials and only a few observations have shown so far the feasibility of TAVR as a bridge or salvage therapy for patients with end-stage liver diseases (n = 6) or before kidney transplantation (n = 1). [12][13][14][15][16] We report herein 3 additional cases of cirrhotic patients with severe AS who benefited from a TAVR procedure while awaiting LT.…”

Transcatheter Aortic Valve Replacement Restoring Candidacy for Liver Transplant in Patients With Cirrhosis

“…14 In 2019, Kaliamoorthy et al described 2 cases of patients with infective endocarditis-induced acute aortic regurgitation similar to our case who underwent TAVR and then a subsequent living donor liver transplant successfully. 15 When discussing the potential for TAVR, the concern of the safety of this cardiac procedure in a hemodynamically vulnerable cirrhotic patient population must also be brought to light. A recent 2021 investigation studied the 30-day and 1-year post-TAVR recovery course of over 300 patients with end-stage liver and/or kidney disease in comparison with a population without those comorbidities.…”

Perioperative management of adult living donor liver transplantation: Part 1 – recipients

“…110 Additionally, LDLT allows for optimal timing of combined procedures such as coronary artery bypass surgery with LDLT or staged procedures such as LDLT after transcatheter aortic valve insertion. 111,112 Likewise, there is concern surrounding LDLT in patients with cirrhosis secondary to alcoholism due to potential for relapse, but these patients' shortand long-term outcomes have been good. [113][114][115] Given the potential for mortality and significant morbidity for the LDLT donor, the appropriateness of LDLT is controversial for highrisk and high MELD patients such as those with fulminant hepatic failure (FHF) in which the right lobe is almost exclusively necessary.…”

“…Patients with moderate aortic or mitral valve stenosis and lower MELD scores can have an LDLT safely then undergo cardiac surgery when their valvular disease progresses 110 . Additionally, LDLT allows for optimal timing of combined procedures such as coronary artery bypass surgery with LDLT or staged procedures such as LDLT after transcatheter aortic valve insertion 111,112 . Likewise, there is concern surrounding LDLT in patients with cirrhosis secondary to alcoholism due to potential for relapse, but these patients' short‐ and long‐term outcomes have been good 113–115 …”