Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations

Abstract

Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis, thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

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

“…(18) In addition, some studies have already shown the association of those factors with CAD in patients with end-stage liver disease. (4,18) Finally, a recent multidisciplinary consensus recommendation suggests coronary angiography in all candidates with diabetes alone or at least 2 other CVR factors, (22) thus reinforcing the appropriateness of our selected high-risk population. Unfortunately, we were unable to detect a clinical risk profile predictive of severe coronary disease.…”

A simple clinical calculator for assessing cardiac event risk in liver transplant candidates: The cardiovascular risk in orthotopic liver transplantation score

“…LT candidates with traditional absolute cardiac contraindications to proceeding with transplant were not included in this analysis. Traditional absolute cardiac contraindications at most transplant centers include: (1) decreased left ventricular systolic function (ejection fraction <45%), (2) decreased right ventricular function and/or significant right ventricular dilation, (3) uncontrolled pulmonary hypertension defined as mean pulmonary artery pressure ≥35 mm Hg at rest despite maximal medical management, (4) significant uncorrectable structural valvular abnormalities (aortic stenosis, mitral stenosis, aortic regurgitation, tricuspid regurgitation), (5) uncorrectable coronary artery disease with induced ischemia on stress testing, (6) significant carotid disease in particular if symptomatic, and (7) diffuse atherosclerotic disease involving multiple organs …”

Coronary artery disease in decompensated patients undergoing liver transplantation evaluation

“…(6) Even without our requested findings, we would make the statement that all HR-NASH liver transplant candidates should undergo pretransplantation coronary angiography given the high pretest probability for obstructive CAD and the inferior posttransplant outcomes. In further support of this statement, a recent multidisciplinary consensus recommendation by VanWagner et al (10) suggests performing coronary angiography in all candidates with diabetes alone or 2 traditional cardiovascular risk factors (Grade 2C evidence). Further multicenter, largescale prospective studies to better validate these recommendations seems warranted at this time.Ultimately, our goal as liver transplant providers and researchers is to maximize organ utility given the inequity between supply and demand.…”