Transcatheter aortic valve implantation as rescue therapy for liver transplant candidates with aortic valve stenosis

Abstract

TO THE EDITORS:Mortality rates as high as 29% have been reported for patients with end-stage liver disease (ESLD) who undergo cardiac surgery, with postoperative liver failure, sepsis, and bleeding accounting for these rates. 1 In noncardiac surgery scenarios, including liver transplantation, severe aortic stenosis carries a 31% perioperative risk of fatal and nonfatal cardiovascular events. 2 Consequently, a clinical dilemma emerges in cases of concurrent aortic stenosis and ESLD because the presence of one condition limits the treatment of the other. Moreover, in cases of congestive liver disease associated with aortic valve stenosis, treatment of the valvular disease remains the only therapeutic option for effectively improving liver function.We hypothesized, therefore, that transcatheter aortic valve implantation (TAVI) could be used as a less invasive alternative treatment for patients with concomitant ESLD and high-grade aortic valve stenosis and eventually turn these patients into eligible candidates for liver transplantation.To the best of our knowledge, the use of TAVI for patients with ESLD and severe aortic valve stenosis has not been reported previously. Our objective here is to report 2 patients with ESLD who benefited from TAVI therapy. This report was approved by the Institutional Review Committee.Patient 1, a 63-year-old man with ESLD, was admitted to the emergency room with dyspnea, lung crackles, jugular distension, diffuse edema, and a systolic murmur in the aortic area. Transthoracic echocardiography showed severe aortic stenosis with maximum and mean pressure gradients of 71 and 48 mm Hg, respectively. The indexed aortic valve area was 0.55 cm 2 . The end-diastolic left ventricular diameter was 55 mm, and the ejection fraction was 61% (Table 1). A previous diagnosis of cirrhosis due to a chronic hepatitis C virus infection complicated by hepatocellular carcinoma was established. Because of the thrombocytopenia, a platelet count of 60,000/ mm 3 , and a Model for End-Stage Liver Disease score of 16 points, the patient was considered at high risk for cardiac surgery. TAVI with an Edwards SAPIEN XT system (number 26, Edwards Lifesciences, Irvine, CA) was performed. The postprocedural period was uneventful, and the symptoms of heart failure improved during the course of the following week. Antiplatelet therapy was not prescribed because of the thrombocytopenia. After 1 month, his cardiac recovery was clinically complete, and this meant that the patient was considered eligible for liver transplantation. The patient underwent orthotopic liver transplantation 6 months after TAVI. No cardiovascular complications were observed, and the patient was discharged 5 days after the procedure.Patient 2, a 77-year-old man with a past history of diabetes mellitus, systemic arterial hypertension, and coronary artery disease with previous surgical myocardial revascularization, was referred for weekly paracentesis as a result of refractory ascites. He was diagnosed with nonalcoholic steatohepatitis complicated by ...

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.…”

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

“…Silvestre et al 26 first reported the usage of TAVI in severe AS in 2 LT candidates on the waiting list. One of them underwent successful OLT and the other patient did not require LT due to clinical improvement.…”

Elderly patients with multiple comorbidities: insights from the bedside to the bench and programmatic directions for this new challenge in lung transplantation

“…These inventions enable patients who were not previously considered for organ transplantation to become viable candidates in the absence of other contraindications. Interestingly, in patients with end‐stage liver diseases, the issue of concurrent severe aortic valve stenosis has been well addressed, and acceptable outcomes after liver transplantation in patients who have undergone TAVR have been reported . Similar work is needed in patients with end‐stage lung disease.…”