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

Abstract

Limited data regarding the optimal risk assessment strategy for evaluating candidates for orthotopic liver transplantation (OLT) exist. Our center has adopted a policy of performing cardiac catheterization (CATH) in patients with predefined risk factors, and this is followed by percutaneous coronary intervention (PCI) when it is indicated, even in the presence of negative stress test findings. The aim of this single-center, retrospective study of all patients who underwent OLT between 2000 and 2010 was to assess the effect of our policy on cardiovascular (CV) complications and survival rates after OLT. Data, including 1-year all-cause and CV mortality, postoperative myocardial infarctions (MIs), and frequencies of CATH and PCI, were abstracted. The study was divided into 3 subperiods to reflect the changes in policy over this period: The rate of catheterization increased during the 3 time periods (P < 0.001), as did the rate of PCI (P < 0.05). Allcause mortality decreased over the periods (P < 0.001), as did the MI rate (P < 0.001). Thirty-five of the 57 patients requiring PCI had normal stress tests. The mortality rate associated with postoperative MIs was significantly higher than the overall all-cause mortality rate. In conclusion, a significant improvement in the overall survival rate over the 3 analyzed time periods was noted. Increases in the frequencies of CATH and PCI corresponded to significant reductions in postoperative MIs and 1-year all-cause mortality rates. The increased use of CATH and PCI was associated with reduced overall allcause mortality through reductions in the incidence of both fatal and nonfatal MIs. Further analyses of the role of stress testing and CATH in evaluating and treating patients before OLT are required to optimize this process. The optimal strategy for assessing cardiovascular (CV) risk in patients undergoing orthotopic liver transplantation (OLT) remains to be defined. Mortality related to CV events after OLT is increasingly being recognized, with a recent report noting cumulative risks of CV events at 1 and 3 years of 4.5% and 10.1%,

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

“…Our study is not without limitations. First, it is difficult to extrapolate our results to other populations with a different cardiovascular baseline risk, which is probably lower in our series than in those reported in North America and northern Europe . On the other hand, differences in etiology may contribute to a different prevalence of CAD.…”

“…As for therapy, our protocol stated that all stenosis >70% should be treated aggressively, whereas in 50%‐70% stenosis, the decision should be individualized. Although treatment of moderate stenosis is controversial, a recent study reported good outcomes when all patients with moderate stenosis were treated, regardless of stress test results …”

“…Interestingly, arteriosclerosis involving several coronary arteries seems to have more impact on the prognosis than the severity of stenosis in a single artery . However, information about the effectiveness of the different screening protocols to detect and treat CAD before LT remains scarce and controversial . This fact is increasingly important in the growing population of patients with nonalcoholic steatohepatitis (NASH) and end‐stage liver disease who are candidates for LT.…”

Review of anesthesia in liver transplantation

“…The benefit of heart catheterization is that the presence of CAD can be immediately confirmed and treated with percutaneous coronary intervention. 119 This measure has reduced the perioperative mortality rate through reductions in the incidence of both fatal and nonfatal myocardial infarctions in LT. 119 Cardiopulmonary exercise testing is an important clinical tool to evaluate exercise capacity and exercise intolerance, and to predict the outcome of the patients. 120 Cardiopulmonary exercise testing is a sensitive and specific predictor for short-term survival of patients in the waiting list for LT 121 and after LT. 122 …”

Coronary Computed Tomography Angiography in Combination with Coronary Artery Calcium Scoring for the Preoperative Cardiac Evaluation of Liver Transplant Recipients

“…Significant CAD is defined as a more than 50% decrease in the lumen diameter resulting in a hemodynamically significant reduction in coronary blood flow [43]. The increased use of coronary angiography and percutaneous coronary intervention before orthotopic liver transplant is also associated with significant reductions in postoperative coronary events and all-cause mortality [44]. In contrast, coronary interventions do not reduce mortality rates in orthotopic liver transplant patients with severe CAD [45].…”