Multivessel coronary artery disease predicts mortality, length of stay, and pressor requirements after liver transplantation

Abstract

The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P ¼ 0.046), increased length of stay (22 versus 15 days, P ¼ 0.050), and postoperative pressor requirements (27% versus 4%, P ¼ 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup.

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

“…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).…”

Prevalence and Prediction of Coronary Artery Disease in Patients With Liver Cirrhosis

“…It is most important to predict cardiac outcomes in adult patients who are undergoing LT, because cardiovascular disease has been found to be one of the most common causes of complications, and even death, in LT patients with functional grafts, particularly in cases with preexisting cardiac histories. 13,48 Our data indicate that multivessel CAD, which is thought to be a powerful predictor of post-LT mortality, 37 may be more common in cirrhotic patients, despite the fact that the prevalence of obstructive lesions in the cirrhotic patients was equivalent to that in the noncirrhotic individuals. Furthermore, LC patients were also at higher risk of nonobstructive CAD with more unfavorable course than normal coronary arteries, especially in extensive disease, although it remains to be seen whether management of such patients might improve outcomes.…”

“…In fact, a previous study by Yong et al reported that multivessel disease, a wellestablished predictor of adverse cardiovascular events in both obstructive and nonobstructive disease, 28,30 was associated with higher mortality post-LT, which was independent of the severity of coronary stenosis. 37 A protective role of cirrhosis against atherosclerotic events has occasionally been reported in postmortem studies. 5,6 This might in principle be supported by the favorable cardiovascular risk profiles of cirrhosis per se in terms of the hemostatic defects such as impaired coagulation, thrombocytopenia, and platelet dysfunction, low blood pressure and cholesterol levels, and high levels of circulating estrogens, as well, seen in previous and, in part, also in the current series.…”

Cardiovascular and renal complications in patients receiving a solid-organ transplant

“…Early studies upon renal and liver transplant candidates suggested a strong correlation between pretransplant CAD and post-transplant cardiovascular morbidity; however, recent data challenge this association [23,24 ]. Yong et al [24 ] retrospectively examined an 83 OLT candidate cohort to determine the contribution of CAD to post-transplant mortality.…”

“…The authors did identify a subset of candidates with angiographically documented multivessel CAD that was associated with post-OLT mortality, even in the absence of severe (70%) coronary artery stenosis, and proposed this as their principal justification for coronary angiography [24 ].…”