Role of cardiovascular intervention as a bridge to liver transplantation

Abstract

End stage liver disease (ESLD) is associated with many specific derangements in cardiovascular physiology, which influence perioperative outcomes and may profoundly influence diagnostic and management strategies in the preoperative period. This review focuses on evidence-based diagnosis and management of coronary, hemodynamic and pulmonary vascular disease in this population with an emphasis on specific strategies that may provide a bridge to transplantation. Specifically, we address the underlying prevalence of cardiovascular disease states in the ESLD population, and relevant diagnostic criteria thereof. We highlight traditional and non-traditional predictors of cardiovascular outcomes following liver transplant, as well as data to guide risk-factor based diagnostic strategies. We go on to discuss the alterations in cardiovascular physiology which influence positive- and negative-predictive values of standard noninvasive testing modalities in the ESLD population, and review the data regarding the safety and efficacy of invasive testing in the face of ESLD and its co-morbidities. Finally, based upon the totality of available data, we outline an evidence-based approach for the management of ischemia, heart failure and pulmonary vascular disease in this population. It is our hope that such evidence-driven strategies can be employed to more safely bridge appropriate candidates to liver transplant, and to improve their cardiovascular health and outcomes in the peri-operative period.

Keywords: Perioperative management; Liver transplantation; Coronary heart disease; Cirrhotic cardiomyopathy; Heart failure; Pulmonary vascular disease

Core tip: The population of liver transplant candidates is rapidly evolving with respect to advanced age, etiology and co-morbidities. Consequently, the cardiovascular risk profiles of these candidates have increased. At the same time, the availability of interventions, both mechanical and pharmacologic, for cardiovascular conditions has allowed previously unsuitable candidates to go on to liver transplantation. Therefore, it is imperative to understand how to define the cardiovacular risk profile of liver transplant candidates and the pre-transplant treatment options available to them.