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Gualandro DM, Fornari LS, Caramelli B, Abizaid AAC, Gomes BR, Tavares CDAM, Fernandes CJCDS, Polanczyk CA, Jardim C, Vieira CLZ, Pinho C, Calderaro D, Schreen D, Marcondes-Braga FG, Souza FD, Cardozo FAM, Tarasoutchi F, Carmo GAL, Kanhouche G, Lima JJGD, Bichuette LD, Sacilotto L, Drager LF, Vacanti LJ, Gowdak LHW, Vieira MLC, Martins MLFM, Lima MSM, Lottenberg MP, Aliberti MJR, Marchi MFDS, Paixão MR, Oliveira Junior MTD, Yu PC, Cury PR, Farsky PS, Pessoa RS, Siciliano RF, Accorsi TAD, Correia VM, Mathias Junior W. Guideline for Perioperative Cardiovascular Evaluation of the Brazilian Society of Cardiology - 2024. Arq Bras Cardiol 2024; 121:e20240590. [PMID: 39442131 DOI: 10.36660/abc.20240590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024] Open
Affiliation(s)
- Danielle Menosi Gualandro
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
- University Hospital Basel, Basel - Suíça
| | - Luciana Savoy Fornari
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
- Fundação Zerbini, São Paulo, SP - Brasil
| | - Bruno Caramelli
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Alexandre Antonio Cunha Abizaid
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | - Carisi Anne Polanczyk
- Hospital de Clínicas da Universidade Federal do Rio Grande do Sul (UFRS), Porto Alegre, RS - Brasil
| | - Carlos Jardim
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Claudio Pinho
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Campinas, SP - Brasil
- Clinica Pinho, Campinas, SP - Brasil
| | - Daniela Calderaro
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Dirk Schreen
- Hospital São Carlos, Rede D'Or, Fortaleza, CE - Brasil
- Hospital Universitário Walter Cantidio da Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
- Instituto de Medicina Nuclear, Fortaleza, CE - Brasil
| | - Fabiana Goulart Marcondes-Braga
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Fábio de Souza
- Escola de Medicina e Cirurgia da Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ - Brasil
| | - Francisco Akira Malta Cardozo
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Gabriel Assis Lopes Carmo
- Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Evangélico de Belo Horizonte, Belo Horizonte, MG - Brasil
- Hospital Orizonti, Belo Horizonte, MG - Brasil
| | | | - José Jayme Galvão de Lima
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Luciana Dornfeld Bichuette
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Luciana Sacilotto
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
- Fundação Zerbini, São Paulo, SP - Brasil
| | - Luciano Ferreira Drager
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | - Luis Henrique Wolff Gowdak
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Márcio Silva Miguel Lima
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Marcos Pita Lottenberg
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Felippi de Sá Marchi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Milena Ribeiro Paixão
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Pai Ching Yu
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | - Rinaldo Focaccia Siciliano
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Tarso Augusto Duenhas Accorsi
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Vinícius Machado Correia
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Junior
- Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(HCFMUSP), São Paulo, SP - Brasil
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Mouratidou C, Pavlidis ET, Katsanos G, Kotoulas SC, Mouloudi E, Tsoulfas G, Galanis IN, Pavlidis TE. Hepatic ischemia-reperfusion syndrome and its effect on the cardiovascular system: The role of treprostinil, a synthetic prostacyclin analog. World J Gastrointest Surg 2023; 15:1858-1870. [PMID: 37901735 PMCID: PMC10600776 DOI: 10.4240/wjgs.v15.i9.1858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 09/21/2023] Open
Abstract
Hepatic ischemia-reperfusion syndrome has been the subject of intensive study and experimentation in recent decades since it is responsible for the outcome of several clinical entities, such as major hepatic resections and liver transplantation. In addition to the organ's post reperfusion injury, this syndrome appears to play a central role in the dysfunction of distant tissues and systems. Thus, continuous research should be directed toward finding effective therapeutic options to improve the outcome and reduce the postoperative morbidity and mortality rates. Treprostinil is a synthetic analog of prostaglandin I2, and its experimental administration has shown encouraging results. It has already been approved by the Food and Drug Administration in the United States for pulmonary arterial hypertension and has been used in liver transplantation, where preliminary encouraging results showed its safety and feasibility by using continuous intravenous administration at a dose of 5 ng/kg/min. Treprostinil improves renal and hepatic function, diminishes hepatic oxidative stress and lipid peroxidation, reduces hepatictoll-like receptor 9 and inflammation, inhibits hepatic apoptosis and restores hepatic adenosine triphosphate (ATP) levels and ATP synthases, which is necessary for functional maintenance of mitochondria. Treprostinil exhibits vasodilatory properties and antiplatelet activity and regulates proinflammatory cytokines; therefore, it can potentially minimize ischemia-reperfusion injury. Additionally, it may have beneficial effects on cardiovascular parameters, and much current research interest is concentrated on this compound.
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Affiliation(s)
| | - Efstathios T Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Georgios Katsanos
- Department of Transplantation, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | | | - Eleni Mouloudi
- Intensive Care Unit, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Georgios Tsoulfas
- Department of Transplantation, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Ioannis N Galanis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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3
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Kwon HM, Kim JH, Yang JW, Hwang GS. Temporary postoperative myocardial injury and long-term survival in liver transplant patients with coronary artery disease. Anesth Pain Med (Seoul) 2022; 17:404-411. [DOI: 10.17085/apm.22167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Coronary artery disease (CAD) is increasing worldwide due to the aging population and cardiometabolic syndrome. However, the extent of postoperative myocardial injury, the most common cause of death during the 30 days after noncardiac surgery, remains unclear with respect to liver transplant (LT) patients with CAD. We examined the link between post-LT high sensitivity cardiac troponin I (hs_cTnI) and long-term survival according to liver disease severity.Methods: Consecutive patients who underwent LT (n = 3,220) from 2010 to 2020 were evaluated retrospectively. CAD was defined as a history of coronary artery bypass surgery or percutaneous intervention, or previous myocardial infarction. Peak hs_cTnI levels within 30 days post-transplant were compared in patients with and without CAD. The primary endpoint was defined as an all-cause mortality at 12 years following LT. Secondary endpoints include peak hs_cTnI level within post-transplant 30 days and 30-day mortality. Survival analysis was performed using the Kaplan–Meier method.Results: CAD patients (n = 264, 8.2%) had higher peak hs_cTnI levels within 30 days post-LT than those without CAD (median [interquartile]: 0.068 [0.030–0.154] vs. 0.087 [0.037–0.203] ng/ml, respectively; P = 0.004); however, the mortality rate was comparable (14.7% vs. 14.8%, respectively, P = 0.999), at 12 years, and 1.9% vs. 1.1% (P = 0.522) at 30 days, respectively, at 30 days. Subgroup analysis with stratified liver disease severity identified a similar risk of long-term mortality.Conclusions: Although the peak hs_cTnI level within 30 days was higher in revascularized or treated CAD patients after LT compared those without CAD, long-term mortality rates at 12 years and 30-day mortality rate were comparable.
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Maggi P, Calò F, Messina V, Stornaiuolo G, Stanzione M, Rinaldi L, De Pascalis S, Macera M, Coppola N. Cardiovascular disease risk in liver transplant recipients transplanted due to chronic viral hepatitis. PLoS One 2022; 17:e0265178. [PMID: 35294954 PMCID: PMC8926187 DOI: 10.1371/journal.pone.0265178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Cardiovascular disease (CVD) is a major cause of morbidity and mortality after liver transplantation, mostly in patients transplanted for nonalcoholic steatohepatitis, obesity and diabetes. Few data exist on cardiovascular diseases among patients transplanted for viral hepatitis.
Objective
Our aim is to clarify the cardiovascular risk and subclinical vascular damage among liver transplant recipients for chronic viral hepatitis (i.e. hepatits C virus, hepatis B virus and hepatitis D virus infection).
Methods
Adult patients (age ≥ 18 years) with orthotopic liver transplants (OLT) due to viral hepatitis who signed informed consent, and were admitted for a routine follow-up between June 2019 and September 2020 at the Infectious Disease outpatient clinic of the University of Campania Luigi Vanvitelli, Naples, Italy, were prospectively enrolled. An estimation of cardiovascular risk was assessed using three main risk charts, echocolor-Doppler of epiaortic vessels was performed to assess subclinical Intima-Media changes.
Results
A total of 161 patients were evaluated; of these 15 were excluded because not affected by viral hepatitis. 146 patients were considered. 83 patients (56.8%) were considered at high cardiovascular risk according to Framingham, 54 patients (36.9%) to American Heart Association Arteriosclerotic Cardiovascular Disease (ASCVD) score and 19 (13.0%) to Heart Score. Only 8 patients (5.4%) showed a normal carotid ultrasound, while 52 patients (35.6%) had a carotid artery Intima-Media Thickness (IMT) and 86 (58.9%) an atherosclerotic plaque.
Conclusions
Liver transplant recipients for virus-related associated liver disease are, in light of the high percentage of carotid lesions, at high risk of CVD. Risk charts compared to subclinical carotid lesions which represent damage already established and a real localization of the disease, seem to underestimate the cardiovascular risk. A chronic inflammatory status, could play a key role. It’s important to raise the awareness of cardiovascular risk in liver transplant patients to prevent cardiovascular diseases and improve the timing of early diagnosis of premature vascular lesions.
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Affiliation(s)
- Paolo Maggi
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
- * E-mail:
| | - Federica Calò
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gianfranca Stornaiuolo
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Stanzione
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefania De Pascalis
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Margherita Macera
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
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Hakeem AR, Fathima R, Padmanaban H, Haribabu K, Rajalingam R, Palaniappan K, Jothimani D, Kanagavelu R, Rajakumar A, Kaliamoorthy I, Reddy MS, Rela M. Propensity Score-Matched Analysis of Posttransplant Outcomes in Living Donor Liver Transplantation for Older Adult Recipients. Liver Transpl 2021; 27:1273-1282. [PMID: 33787013 DOI: 10.1002/lt.26061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/15/2021] [Accepted: 03/04/2021] [Indexed: 02/07/2023]
Abstract
The impact of increasing recipient age on morbidity and mortality following living donor liver transplantation (LDLT) remains controversial. The study aims to analyze the impact of recipient age on outcomes following LDLT. Data on adult LDLTs performed between November 2009 and February 2020 were retrieved from a prospectively maintained database. Patients were stratified into 2 groups based on recipient age: 18 to 65 years (younger adults) and >65 years (older adults). Propensity score matching (PSM) using nearest-neighbor matching was used to match each older recipient with up to 2 younger adult recipients using multiple preoperative parameters. Outcomes evaluated were duration of ventilation, need for reintubation, tracheostomy, intensive care unit (ICU) readmission, length of ICU and hospital stays, postoperative complications, reoperation within 90 days, and patient survival. A total of 801 adult LDLT recipients were included in the study; 751 (93.7%) were younger adults, and 50 (6.3%) were older adults. Older recipients were more likely to be diabetic (60.0% versus 39.7%) and hypertensive (44.0% versus 20.4%) with preexisting cardiac disease (28.0% versus 11.2%). However, their pretransplant Model for End-Stage Liver Disease score was significantly lower (14.5 versus 17.7), and they were more likely to receive a transplant because of hepatocellular carcinoma (38.0% versus 17.7%). Older recipients had longer durations of ventilation after LT both before (3.7 versus 1.9 days) and after PSM (4.0 versus 1.5 days). After PSM, the 30-day (13.0% versus 2.4%), 90-day (15.2% and 2.4%), and overall mortality rates (21.7% versus 7.1%) were significantly higher for older recipients when compared with younger recipients. There was no difference between the younger and older recipients with respect to other postoperative outcomes. This propensity score-matched study shows that the older LDLT recipients have higher 30-day, 90-day, 1-year, and 5-year mortality rates when compared with matched younger counterparts.
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Affiliation(s)
- Abdul Rahman Hakeem
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Rukhaiya Fathima
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Hrishikesh Padmanaban
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Kulaseharan Haribabu
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Rajesh Rajalingam
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Kumar Palaniappan
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Dinesh Jothimani
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Rathan Kanagavelu
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Akila Rajakumar
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Ilankumaran Kaliamoorthy
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Mettu Srinivas Reddy
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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Abele JT, Raubenheimer M, Bain VG, Wandzilak G, AlHulaimi N, Coulden R, deKemp RA, Klein R, Williams RG, Warshawski RS, Lalonde LD. Quantitative blood flow evaluation of vasodilation-stress compared with dobutamine-stress in patients with end-stage liver disease using 82Rb PET/CT. J Nucl Cardiol 2020; 27:2048-2059. [PMID: 30456495 DOI: 10.1007/s12350-018-01516-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Our aim was to determine if end-stage liver disease (ESLD) is associated with an attenuated response to vasodilator-stress or dobutamine-stress using 82Rb-PET MPI with blood flow quantification. METHODS AND RESULTS Pre-liver transplant patients who had a normal dipyridamole-stress (n = 27) or dobutamine-stress (n = 26) 82Rb PET/CT MPI study with no identifiable coronary artery calcium were identified retrospectively and compared to a prospectively identified low-risk of liver disease dipyridamole-stress control group (n = 20). The dipyridamole-stress liver disease group had a lower myocardial flow reserve (MFR) (1.89 ± 0.79) than the control group (2.79 ± 0.96, P < .05). The dobutamine-stress group had a higher MFR than both other groups (3.69 ± 1.49, P < .05). A moderate negative correlation between MELD score and MFR was demonstrated for the dipyridamole-stress liver disease group (r = - 0.473, P < .05). This correlation was not observed for the dobutamine-stress liver disease group (r = - 0.253, P = .21). The liver failure group as a whole (n = 53) had a higher resting myocardial blood flow (0.97 ± 0.33 mL/min/g) than the control group (0.82 ± 0.26, P < .05). CONCLUSION Dipyridamole demonstrates an attenuated vasodilatory response in ESLD patients compared to a non-ESLD control group related to higher resting blood flow and comparatively reduced stress blood flow. Dobutamine does not demonstrate this effect implying it may be the preferred pharmacologic MPI stress agent for ESLD patients.
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Affiliation(s)
- Jonathan T Abele
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.
- Department of Radiology and Diagnostic Imaging, 2A2.42 Walter C MacKenzie Health Sciences Centre, University of Alberta, 8440 - 112 Street NW, Edmonton, Alberta, T6G 2B7, Canada.
| | - Monique Raubenheimer
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Vincent G Bain
- Liver Unit, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Greg Wandzilak
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Naji AlHulaimi
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Coulden
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Robert A deKemp
- Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ran Klein
- Division of Nuclear Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Randall G Williams
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert S Warshawski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Lucille D Lalonde
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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7
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Steggerda JA, Mahendraraj K, Todo T, Noureddin M. Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge. World J Gastroenterol 2020; 26:4018-4035. [PMID: 32821068 PMCID: PMC7403794 DOI: 10.3748/wjg.v26.i28.4018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/07/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.
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Affiliation(s)
- Justin A Steggerda
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Krishnaraj Mahendraraj
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Tsuyoshi Todo
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Mazen Noureddin
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
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8
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Kwon HM, Moon YJ, Jung KW, Park YS, Kim KS, Jun IG, Song JG, Hwang GS. Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post-Liver Transplantation Mortality. Hepatology 2020; 71:1364-1380. [PMID: 31464025 DOI: 10.1002/hep.30913] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/22/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Enhanced sympathetic nervous activation and peripheral vasodilation in end-stage liver disease (ESLD) may limit the importance of left ventricular ejection fraction (LVEF) as an influential prognosticator. We sought to understand the LVEF and cardiac dimensions in ESLD patients in order to define the LVEF threshold to predict all-cause mortality after liver transplantation (LT). APPROACH AND RESULTS Data were collected prospectively from the Asan LT Registry between 2008 and 2016, and outcomes were retrospectively reviewed. LVEF, end-diastolic volume index (EDVI), and end-diastolic elastance (Eed) were measured by preoperative echocardiography. Of 2,799 patients, 452 (16.2%) had LVEF ≤ 60%, with 29 (1.0%) having LVEF < 55% and 269 (9.6%) had LVEF ≥ 70%. Over a median of 5.4-year follow-up, 329 (11.8%) patients died: 104 (3.7%) died within 90 days. LVEF (range, 30%-81%) was directly proportionate to Model for End-stage Liver Disease (MELD) scores, an index of liver disease severity, in survivors but showed a fixed flat-line pattern in nonsurvivors (interaction P = 0.004 between groups), with lower EDVI (P = 0.013) and higher Eed (P = 0.001) in the MELD ≥ 20 group. Patients with LVEF ≤ 60% had higher 90-day (13% vs. 7.4%; log rank, P = 0.03) and median 5.4-year (26.7% vs. 16.2%; log rank, P = 0.003) mortality rates in the MELD ≥ 20 group, respectively, compared to those with LVEF > 60%. Specifically, in the MELD > 35 group, median 5.4-year mortality rate was 53.3% in patients with LVEF ≤ 60% versus 24% in those with LVEF > 60% (log rank P < 0.001). By contrast, mortality rates of LVEF ≤ 60% and > 60% were similar in the MELD < 20 group (log rank P = 0.817). CONCLUSIONS LVEF ≤ 60% is strongly associated with higher post-LT mortality rates in the MELD ≥ 20 group, indicating the need to appraise both LVEF and liver disease severity simultaneously. Enhanced diastolic elastance with low EDVI provides insights into pathogenesis of low LVEF in nonsurvivors with MELD ≥ 20.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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9
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Plotogea O, Ilie M, Sandru V, Chiotoroiu A, Bratu O, Diaconu C. Cardiovascular and Metabolic Consequences of Liver Transplantation: A Review. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:489. [PMID: 31443295 PMCID: PMC6722584 DOI: 10.3390/medicina55080489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 12/14/2022]
Abstract
Liver transplantation (LT) is considered the curative treatment option for selected patients who suffer from end-stage or acute liver disease or hepatic malignancy (primary). After LT, patients should be carefully monitored for complications that may appear, partially due to immunosuppressive therapy, but not entirely. Cardiovascular diseases are frequently encountered in patients with LT, being responsible for high morbidity and mortality. Patients with underlying cardiovascular and metabolic pathologies are prone to complications after the transplant, but these complications can also appear de novo, mostly associated with immunosuppressants. Metabolic syndrome, defined by obesity, hypertension, dyslipidemia, and hyperglycemia, is diagnosed among LT recipients and is aggravated after LT, influencing the long-term survival. In this review, our purpose was to summarize the current knowledge regarding cardiovascular (CV) diseases and the metabolic syndrome associated with LT and to assess their impact on short and long-term morbidity and mortality.
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Affiliation(s)
- Oana Plotogea
- Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Gastroenterology Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Madalina Ilie
- Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Gastroenterology Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Vasile Sandru
- Gastroenterology Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Alexandru Chiotoroiu
- Surgery Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Ovidiu Bratu
- Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Urology Clinic, Emergency University Central Military Hospital, 010242 Bucharest, Romania
| | - Camelia Diaconu
- Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania.
- Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania.
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10
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Saugel B, Flick M, Bendjelid K, Critchley LAH, Vistisen ST, Scheeren TWL. Journal of clinical monitoring and computing end of year summary 2018: hemodynamic monitoring and management. J Clin Monit Comput 2019; 33:211-222. [PMID: 30847738 PMCID: PMC6420447 DOI: 10.1007/s10877-019-00297-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 12/05/2022]
Abstract
Hemodynamic management is a mainstay of patient care in the operating room and intensive care unit (ICU). In order to optimize patient treatment, researchers investigate monitoring technologies, cardiovascular (patho-) physiology, and hemodynamic treatment strategies. The Journal of Clinical Monitoring and Computing (JCMC) is a well-established and recognized platform for publishing research in this field. In this review, we highlight recent advancements and summarize selected papers published in the JCMC in 2018 related to hemodynamic monitoring and management.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg- Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Moritz Flick
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg- Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Karim Bendjelid
- Department of Anesthesiology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Lester A H Critchley
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shantin, N.T., Hong Kong.,The Belford Hospital, Fort William, The Highlands, Scotland, UK
| | - Simon T Vistisen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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11
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Kwon HM, Hwang GS. Cardiovascular dysfunction and liver transplantation. Korean J Anesthesiol 2018; 71:85-91. [PMID: 29619780 PMCID: PMC5903113 DOI: 10.4097/kjae.2018.71.2.85] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/22/2017] [Accepted: 10/12/2017] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular complications have emerged as the leading cause of death after liver transplantation, particularly among those with advanced liver cirrhosis. Therefore, a thorough and accurate cardiovascular evaluation with clear comprehension of cirrhotic cardiomyopathy is recommended for optimal anesthetic management. However, cirrhotic patients manifest cardiac dysfunction concomitant with pronounced systemic hemodynamic changes, characterized by hyperdynamic circulation such as increased cardiac output, high heart rate, and decreased systemic vascular resistance. These unique features mask significant manifestations of cardiac dysfunction at rest, which makes it difficult to accurately evaluate cardiovascular status. In this review, we have summarized the current knowledge of heart and liver interactions, focusing on the usefulness and limitations of cardiac evaluation tools for identifying high-risk patients.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Dehghani SM, Moshref M, Amoozgar H, Hoseini SAM, Nikeghbalian S. Exercise Performance in Pediatric Liver Transplant Recipients and Its Related Cardiac Function. Pediatr Cardiol 2018; 39:548-554. [PMID: 29243013 DOI: 10.1007/s00246-017-1786-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 11/30/2017] [Indexed: 02/08/2023]
Abstract
The aim of this study was to evaluate an exercise test in pediatric liver transplant recipients and its relation to their cardiac function. This cross-sectional study was conducted on 58 children who had successfully undergone orthotopic liver transplantation at least 6 months prior to the study, with the same age and gender-matched control group. M-mode, Doppler, tissue Doppler echocardiography and an exercise test were performed for all the participants. The VO2 values and METS in patients were less than the control (P = 0.001). Left ventricular posterior wall thickness in systole, left ventricular posterior wall thickness in diastole, interventricular septum diameter in diastole, AT, pulmonary acceleration time, ST and EaT, AaM, and SS had a significant difference between patients and the control group (P value < 0.05). Maximal oxygen consumption (Max VO2) and metabolic equivalent task (METs) values had a significant correlation with tricuspid valve S parameter (P = 0.018, r = 0.310). Max VO2 and METs values did not have a significant correlation with the diastolic dysfunction index, such as E/A and E/Ea. In this study, the exercise test showed decreased functional capacity in liver-transplanted children; however, the echocardiographic evaluation did not reveal any definite correlation with systolic or diastolic dysfunction.
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Affiliation(s)
| | - Mitra Moshref
- Pediatric Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Amoozgar
- Neonatal Research Center and Cardiovascular Research Center, Pediatric Office Nemazee Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran.
| | | | - Saman Nikeghbalian
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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13
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Rimbaş RC, Baldea SM, Guerra RDGA, Visoiu SI, Rimbaş M, Pop CS, Vinereanu D. New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:562-574. [PMID: 29306590 DOI: 10.1016/j.ultrasmedbio.2017.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 06/07/2023]
Abstract
There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child-Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.
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Affiliation(s)
- Roxana Cristina Rimbaş
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Sorina Mihăilă Baldea
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Mihai Rimbaş
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Corina Silvia Pop
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, University and Emergency Hospital, Bucharest, Romania
| | - Dragoş Vinereanu
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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14
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Khanna S, Raval R, Dorotta I. Con: Dynamic Left Ventricular Outflow Tract Obstruction Should Be Considered an “Unexpected” Finding in Patients With End-Stage Liver Disease Undergoing Dobutamine Stress Echocardiography in Preparation for Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 31:2293-2295. [DOI: 10.1053/j.jvca.2017.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Indexed: 01/09/2023]
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15
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D'Avola D, Cuervas-Mons V, Martí J, Ortiz de Urbina J, Lladó L, Jimenez C, Otero E, Suarez F, Rodrigo JM, Gómez MA, Fraga E, Lopez P, Serrano MT, Rios A, Fábrega E, Herrero JI. Cardiovascular morbidity and mortality after liver transplantation: The protective role of mycophenolate mofetil. Liver Transpl 2017; 23:498-509. [PMID: 28160394 DOI: 10.1002/lt.24738] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/15/2016] [Accepted: 01/02/2017] [Indexed: 12/12/2022]
Abstract
Cardiovascular (CV) diseases are recognized longterm causes of death after liver transplantation (LT). The objective of this multicenter study was to analyze the prevalence and the evolution of CV risk factors and CV morbidity and mortality in 1819 LT recipients along 5 years after LT. The influence of baseline variables on survival, morbidity, and mortality was studied. There was a continuous and significant increase of the prevalence of all the CV risk factors (except smoking) after LT. CV diseases were the fourth cause of mortality in the 5 years after LT, causing 12% of deaths during the follow-up. Most CV events (39%) occurred in the first year after LT. Preexisting CV risk factors such as age, pre-LT CV events, diabetes, metabolic syndrome, and hyperuricemia, and mycophenolate-free immunosuppressive therapy, increased post-LT CV morbidity and mortality. The development of new-onset CV risk factors after LT, such as dyslipidemia and obesity, independently affected late CV morbidity and mortality. Tacrolimus and steroids increased the risk of posttransplant diabetes, whereas cyclosporine increased the risk of arterial hypertension, dyslipidemia, and metabolic syndrome. In conclusion, CV complications and CV mortality are frequent in LT recipients. Preexisting CV risk factors, immunosuppressive drugs, but also the early new onset of obesity and dyslipidemia after LT play an important role on late CV complications. A strict metabolic control in the immediate post-LT period is advisable for improving CV risk of LT recipients. Liver Transplantation 23 498-509 2017 AASLD.
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Affiliation(s)
- Delia D'Avola
- Liver Unit, Clinica Universidad de Navarra, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) and Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Valentín Cuervas-Mons
- Liver Transplantation, Internal Medicine, Hospital Clínica Puerta de Hierro, Madrid, Spain
| | - Josep Martí
- Institut de Malaties Digestives i Metabòliques, Hospital Clinic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Jorge Ortiz de Urbina
- Hepatobiliary Surgery and Liver Transplantation Unit, Hospital Universitario de Cruces, Bilbao, Spain
| | - Laura Lladó
- Liver Surgery and Transplant Unit, Hospital Universitari de Bellvitge, Bellvitge Institute for Biomedical Research, Barcelona, Spain
| | - Carlos Jimenez
- Department of Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - Esteban Otero
- Department of Internal Medicine, Abdominal Transplant Unit, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Francisco Suarez
- Liver Transplant Unit, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Juan M Rodrigo
- Gastroenterology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Enrique Fraga
- Department of Hepatology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pedro Lopez
- Department of Surgery, Hospital Ramón y Cajal, Madrid, Spain
| | - M Trinidad Serrano
- Department of Gastroenterology, Liver Unit, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Antonio Rios
- Transplant Unit, Surgery Service, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José Ignacio Herrero
- Liver Unit, Clinica Universidad de Navarra, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) and Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
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16
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17
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Sehgal L, Srivastava P, Pandey CK, Jha A. Preoperative cardiovascular investigations in liver transplant candidate: An update. Indian J Anaesth 2016; 60:12-8. [PMID: 26962249 PMCID: PMC4782417 DOI: 10.4103/0019-5049.174870] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular complications are a major cause of morbidity and mortality in patients with end-stage liver disease (ESLD) undergoing liver transplantation. Identifying candidates at the highest risk of postoperative cardiovascular complications is the cornerstone for optimizing the outcome. Ischaemic heart disease contributes to major portion of cardiovascular complications and therefore warrants evaluation in the preoperative period. Patients of ESLD usually demonstrate increased cardiac output, compromised ventricular response to stress, low systemic vascular resistance and occasionally bradycardia. Despite various recommendations for preoperative evaluation of cardiovascular disease in liver transplant candidates, a considerable controversy on screening methodology persists. This review critically focuses on the rapidly expanding body of evidence for diagnosis and risk stratification of cardiovascular disorder in liver transplant candidates.
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Affiliation(s)
- Lalit Sehgal
- Liver Transplant Anaesthesia and Critical Care (SICU), Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Piyush Srivastava
- Liver Transplant Anaesthesia and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Chandra Kant Pandey
- Department of Anaesthesiology and Critical Care, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Amit Jha
- Liver Transplant Anaesthesia and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
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18
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Voiosu AM, Daha IC, Voiosu TA, Mateescu BR, Dan GA, Băicuş CR, Voiosu MR, Diculescu MM. Prevalence and impact on survival of hepatopulmonary syndrome and cirrhotic cardiomyopathy in a cohort of cirrhotic patients. Liver Int 2015; 35:2547-55. [PMID: 25974637 DOI: 10.1111/liv.12866] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Extrahepatic complications of cirrhosis increase the risk for decompensation of the liver disease and death. Previous studies show common pathogenetic mechanisms involved in the development of hepatopulmonary syndrome and cirrhotic cardiomyopathy. We aimed to assess the link between these entities and their effect on disease-related patient morbidity and mortality. METHODS Seventy-four consecutive cirrhotic patients without prior history of cardiovascular and pulmonary disease were included in a prospective observational study. Routine blood work, arterial blood gas analysis, pulse oximetry measurements, N-terminal pro-brain natriuretic peptide levels and contrast enhanced echocardiography examination with tissue Doppler imaging were performed in all patients. Patients were followed up for a median of 6 months and disease-related adverse events and death were the main outcomes tested. Statistical analysis was conducted according to the presence of hepatopulmonary syndrome or cirrhotic cardiomyopathy. RESULTS Hepatopulmonary syndrome was diagnosed in 17 patients (23%) and cirrhotic cardiomyopathy in 30 patients (40.5%). There was no association between the presence of cirrhotic cardiomyopathy and the existence of mild or moderate hepatopulmonary syndrome. No echocardiographic parameters were useful in predicting the presence of hepatopulmonary syndrome. N-terminal pro-brain natriuretic peptide levels and length of QT interval did not aid in diagnosis of cirrhotic cardiomyopathy. Neither entity had significant influence on disease-related outcomes in the follow-up period. CONCLUSIONS Hepatopulmonary syndrome and cirrhotic cardiomyopathy are independent complications arising in cirrhosis and have a limited influence on morbidity and mortality on a pre-liver transplantation population.
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Affiliation(s)
- Andrei M Voiosu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Ioana C Daha
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Cardiology, Colentina Clinical Hospital, Bucharest, Romania
| | - Theodor A Voiosu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Bogdan R Mateescu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Gheorghe A Dan
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Cardiology, Colentina Clinical Hospital, Bucharest, Romania
| | - Cristian R Băicuş
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
| | - Mihail R Voiosu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine, Bucharest, Romania
| | - Mircea M Diculescu
- "Carol Davila" University of Medicine, Bucharest, Romania.,Department of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania
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19
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Zardi EM, Zardi DM, Chin D, Sonnino C, Dobrina A, Abbate A. Cirrhotic cardiomyopathy in the pre- and post-liver transplantation phase. J Cardiol 2015; 67:125-30. [PMID: 26074443 DOI: 10.1016/j.jjcc.2015.04.016] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/24/2015] [Accepted: 04/16/2015] [Indexed: 12/23/2022]
Abstract
Patients with advanced liver cirrhosis may develop a clinical syndrome characterized by a blunted contractile responsiveness to stress and/or altered diastolic relaxation, called "cirrhotic cardiomyopathy." This syndrome, which is initially asymptomatic, is often misdiagnosed due to the presence of symptoms that characterize other disorders present in patients with advanced liver cirrhosis, such as exercise intolerance, fatigue, and dyspnea. Stress and other conditions such as liver transplantation and transjugular intrahepatic portosystemic shunt (TIPS) may unmask this syndrome. Liver transplantation in this group of patients results in a clinical improvement and can be a cure for the cardiomyopathy. However, post-transplant prognosis depends on the identification of cirrhotics with cardiomyopathy in the pre-transplant phase; an early diagnosis of cirrhotic cardiomyopathy in the pre-transplant phase may avoid an acute onset or worsening of cardiac failure after liver transplantation. Since a preserved left ventricular ejection fraction may mask the presence of cirrhotic cardiomyopathy, the use of newer noninvasive diagnostic techniques (i.e. tissue Doppler, myocardial strain) is necessary to identify cirrhotics with this syndrome, in the pre-transplant phase. A pre-transplant treatment of heart failure in cirrhotics with cardiomyopathy improves the quality of life in this phase and reduces the complications during and immediately after liver transplantation. Since specific therapies for cirrhotic cardiomyopathy are lacking, due to the absence of a clear understanding of the pathophysiology of the cardiomyopathy, further research in this field is required.
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Affiliation(s)
- Enrico Maria Zardi
- Department of Clinical Medicine, University Campus Bio-Medico, Rome, Italy.
| | - Domenico Maria Zardi
- Department of Cardiology, II School of Medicine, University La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Diana Chin
- Department of Cardiology, II School of Medicine, University La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Chiara Sonnino
- Virginia Commonwealth University-VCU Pauley Heart Center, Richmond, VA, USA
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Antonio Abbate
- Virginia Commonwealth University-VCU Pauley Heart Center, Richmond, VA, USA
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