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Arora A, Sharma P, Kumar A, Acharya S, Sarin SK, Duseja A, Puri P, Shah S, Chawla Y, Rao P, Saraya A, Mohanka R, Singh S, Saighal S, Rela M, Vij V, Asthana S, Shukla A, Bhangui P, Saraf N, Maiwall R, Mandot A, Saraswat V, Madan K, Shalimar, Kapoor D, Anand AC, Gupta S, Varghese J, Mehta N. Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation. J Clin Exp Hepatol 2025; 15:102539. [PMID: 40343081 PMCID: PMC12056968 DOI: 10.1016/j.jceh.2025.102539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 02/24/2025] [Indexed: 05/10/2025] Open
Abstract
Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.
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Affiliation(s)
- Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences. Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Praveen Sharma
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences. Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences. Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - S.K. Acharya
- Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, 751024, Odisha, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Delhi, India
| | - Ajay Duseja
- Post Institute of Medical Sciences, Chandigarh, India
| | | | - Samir Shah
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Dr E Borges Road, Parel, Mumbai, 400012, India
| | - Y.K. Chawla
- Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, 751024, Odisha, India
| | - P.N. Rao
- Asian Institute of Gsstroenterology, Hyderabad, India
| | - Anoop Saraya
- All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Mohanka
- Sir HN Reliance Foundation Hospital, Mumbai, India
| | | | | | - Mohamed Rela
- Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Vivek Vij
- Fortis Hospital, Noida, Delhi, India
| | - Sonal Asthana
- Aster CMI Bangalore, Aster RV Bangalore, Aster Whitefield, Bangalore, India
| | - Akash Shukla
- Reliance Foundation Hospital and Research Centre, Mumbai, India
- Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | | | | | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, Delhi, India
| | - Amit Mandot
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Dr E Borges Road, Parel, Mumbai, 400012, India
| | | | | | - Shalimar
- All India Institute of Medical Sciences, New Delhi, India
| | - Dharmesh Kapoor
- Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
- Yashoda Hospital, Hyderabad, India
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, 751024, Odisha, India
| | | | - Joy Varghese
- Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600100, India
| | - Naimish Mehta
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences. Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
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Jothimani D, Kumar Marannan N, Jain K, Krishna A, Rela M. Cardiac Evaluation in Liver Transplant Candidates. J Clin Exp Hepatol 2025; 15:102554. [PMID: 40415922 PMCID: PMC12099453 DOI: 10.1016/j.jceh.2025.102554] [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: 03/08/2023] [Accepted: 03/18/2025] [Indexed: 05/27/2025] Open
Abstract
Liver transplantation (LT) is the only cure for patients with end-stage liver disease. With an increase in the prevalence of obesity and associated metabolic risk factors cardiovascular disease, in particular coronary artery disease is increasingly recognised in patients with liver cirrhosis. Identification and management of these cardiovascular risk factors may influence post-transplant clinical outcomes. A detailed assessment of patients' cardiovascular status is therefore crucial in the decision-making of patients for LT. Identification of patients with CAD requires risk stratification around perioperative and long term post-operative period. Advanced age, male sex, smoking diabetes mellitus, hypertension, obesity and metabolic-associated steatohepatitis (MASH) cirrhosis significantly increase the risk of coronary artery disease (CAD). Patients with these high-risk factors should undergo cardiac investigations with higher sensitivity to identify CAD. Patients with low-risk factors for CAD may undergo cardiac investigations with high specificity. Patients with cirrhosis may also suffer from conditions directly related to liver disease such as cirrhotic cardiomyopathy and porto-pulmonary hypertension, and conditions unrelated to liver disease such as arrhythmias. Rarely, valvular heart disease may be identified during transplant evaluation. Clinicians managing patients for liver transplantation should carefully evaluate cardiovascular risk and treat it appropriately prior to the surgery, to minimise post-transplant complication. A multidisciplinary approach involving transplant physicians, anaesthetists, cardiologists and transplant surgeons is strongly recommended.
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Affiliation(s)
- Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Navin Kumar Marannan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Karan Jain
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Aswin Krishna
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
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3
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O'Connor M, Adler JT, Venardos NM, Ponce-Rivera MS, Fraser CD, Mery CM, Well A. Outcomes of Liver Transplantation in Patients With Congenital Heart Disease and Biliary Atresia. A Multicenter Analysis. Pediatr Transplant 2025; 29:e70110. [PMID: 40448280 DOI: 10.1111/petr.70110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 02/20/2025] [Accepted: 05/19/2025] [Indexed: 06/02/2025]
Abstract
INTRODUCTION Congenital heart disease (CHD) frequently coexists with noncardiac malformations. Among which, biliary atresia (BA) occurs in approximately 5%-15% of patients Despite this, outcomes of liver transplantation (LT) in patients with CHD and BA remain unknown. METHODS A retrospective review of the Pediatric Health Information System (PHIS) database from January 1, 2004 to October 30, 2023. All patients who underwent LT and had a diagnosis of BA were included. Multiorgan transplants were excluded. International Classification of Diseases 9th and 10th editions were utilized to identify patients with a diagnosis consistent with CHD. RESULTS A total of 1677 patients were identified with 983 (59%) female, 811 (5%) white non-Hispanic, and a median age at transplant of 11.6 (interquartile range [IQR]: 7.7-26.6) months. A CHD diagnosis was present in 83 (5%). Overall, the majority of transplants were performed in the CHD population in the modern era (2016-2023) (42/83.51%). CHD had a longer median preoperative length of stay (LOS) compared to non-CHD (1 [1.0-15.0] vs. 1 [0-6.0], p = 0.031). No increased risk of in-hospital mortality was evident (OR: 1.61, 95% CI: 0.37-6.95, p = 0.519). On multivariable analysis, CHD was associated with a 29% (95% CI: 11.04-50.34) increase in LOS (p < 0.001), 25% (95% CI: 6.98-46.47, p = 0.005) increase in postoperative LOS, and was not associated with increased risk for 30-day readmission (OR: 1.14; CI: 0.53-2.45, p = 0.736). Over a median follow-up of 3.5 years (IQR: 0.86-7.78) years, no difference in retransplantation rate was evident. CONCLUSIONS LT in patients with CHD and BA is safe. Although patients with CHD display heightened utilization of in-hospital resources, no discernible variance in long-term outcomes was observed. However, additional research is imperative to comprehensively elucidate the influence of CHD on management decisions and outcomes throughout the liver transplant process.
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Affiliation(s)
- Mario O'Connor
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Department of Pediatrics, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's and UT Health, Texas, Austin, Austin, TX, USA
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Division of Transplant Surgery, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Neil M Venardos
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
| | - Monica S Ponce-Rivera
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Department of Pediatrics, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's and UT Health, Texas, Austin, Austin, TX, USA
| | - Charles D Fraser
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Department of Pediatrics, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
| | - Carlos M Mery
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Department of Pediatrics, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
| | - Andrew Well
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
- Department of Pediatrics, Dell Medical School at the University of Texas, Austin, Austin, TX, USA
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Biolato M, Miele L, Avolio AW, Marrone G, Liguori A, Galati F, Petti A, Tomasello L, Pedicino D, Lombardo A, D'Aiello A, Pompili M, Agnes S, Gasbarrini A, Grieco A. Diagnostic accuracy and cost-effectiveness of the CAR-OLT score in predicting cardiac risk for liver transplantation. World J Transplant 2025; 15. [DOI: 10.5500/wjt.v15.i2.99208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 12/13/2024] [Accepted: 01/14/2025] [Indexed: 02/21/2025] Open
Abstract
BACKGROUND
The CAR-OLT score predicts major adverse cardiovascular events 1 year after liver transplant (LT).
AIM
To test the hypothesis that the CAR-OLT score may help avoid cardiac stress tests in LT candidates.
METHODS
This retrospective single-center cohort study included all adult patients undergoing elective evaluation for first cadaveric donor orthotopic LT for liver cirrhosis with or without hepatocellular carcinoma at Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricerca e Cura a Carattere Scientifico in Rome, Italy. Cardiac contraindications for LT listing were defined after a center-specific cardiac workup, which included cardiac stress tests for most patients. The diagnostic accuracy of the CAR-OLT score was evaluated using the area under the receiver operating characteristic (AUROC) method.
RESULTS
A total of 342 LT candidates were evaluated between 2015 and 2019, with a moderate cardiovascular risk profile (37% diabetes, 34% hypertension, 22% obesity). Of these, 80 (23%) candidates underwent coronary angiography. Twenty-one (6%) candidates were given cardiac contraindications to LT listing, 48% of which were due to coronary artery disease. The CAR-OLT score predicted cardiac contraindications to LT listing with an AUROC of 0.81. The optimal cut-off for sensitivity was a CAR-OLT score ≤ 23, which showed a 99% negative predictive value for cardiac contraindications to LT listing. A total of 84 (25%) LT candidates with a CAR-OLT score ≤ 23 underwent 87 non-invasive cardiac tests and 13 coronary angiographies pre-listing, with estimated costs of approximately 48000€. The estimated savings per patient was €574.70 for the Italian National Health System.
CONCLUSION
A CAR-OLT score ≤ 23 can identify LT candidates who can be safely listed without the need for cardiac stress tests, providing time and cost savings. These findings require external validation.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Luca Miele
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Alfonso W Avolio
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
| | - Giuseppe Marrone
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Antonio Liguori
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Francesco Galati
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Anna Petti
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Lidia Tomasello
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Daniela Pedicino
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
| | - Antonella Lombardo
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
| | - Alessia D'Aiello
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
| | - Maurizio Pompili
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Salvatore Agnes
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, Centro Malattie Apparato Digerente (CEMAD), Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
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5
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Del Carlo C, Santoni L, Fabiani I, Coceani M, Arzilli C, Passino C, Carrai P, Ghinolfi D, Biancofiore GL, Emdin M. Ischemic Heart Disease in Liver Transplant Candidates With High Bleeding Risk: Any Way Out? JACC Case Rep 2025; 30:103303. [PMID: 40409854 DOI: 10.1016/j.jaccas.2025.103303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Accepted: 12/16/2024] [Indexed: 05/25/2025]
Abstract
Coronary artery disease in candidates for liver transplantation is a real challenge because of the need to balance the risks of bleeding and thrombosis. Antiplatelet therapy, essential to prevent thrombotic events, may increase the risk of hemorrhagic complications, especially in the context of hepatic surgery. A 71-year-old woman with end-stage liver disease (ESLD) presented for a pretransplantation evaluation. She received a diagnosis of significant coronary artery disease (CAD), and a multidisciplinary discussion resulted in the option for an invasive treatment with several precautions to minimize her bleeding risk. Because of the intricacy of underlying comorbidities and the elevated perioperative risk, managing CAD in patients with ESLD is particularly challenging. More research and evidence are needed on treating CAD in this patient group. Patients with ESLD who are waiting for liver transplantation should have CAD actively screened. Multidisciplinary treatment is crucial to maximizing the results.
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Affiliation(s)
- Chiara Del Carlo
- Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - Lorenza Santoni
- Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - Iacopo Fabiani
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Coceani
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Chiara Arzilli
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Passino
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Paola Carrai
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa, Medical School and Hospital, Pisa, Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa, Medical School and Hospital, Pisa, Italy
| | | | - Michele Emdin
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
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6
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Devauchelle P, Bignon A, Breteau I, Defaye M, Degravi L, Despres C, Godon A, Guérin R, Lavayssiere L, Lebas B, Maurice A, Monet C, Monsel A, Reydellet L, Roullet S, Rozier R, Guichon C, Weiss E. Perioperative Management During Liver Transplantation: A National Survey From the French Special Interest Group in "Liver Anesthesiology and Intensive Care". Transplantation 2025; 109:671-680. [PMID: 40071909 DOI: 10.1097/tp.0000000000005264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2025]
Abstract
BACKGROUND Perioperative management practices in liver transplantation (LT) evolve very quickly. There are few specific recommendations, often based on a low level of evidence, resulting in wide heterogeneity of practices. METHODS We performed a survey in all 16 French centers in 2021 by focusing on center organization, preoperative cardiovascular assessment, antimicrobial prophylaxis, hemostasis management, intraoperative use of hemodynamic monitoring and renal replacement therapy, immunosuppression, and postoperative prevention of arterial complications and compared it with current recommendations. RESULTS The organization of perioperative LT care involved 1 single team throughout the perioperative LT process in 7 centers (43.7%). The coronary evaluation was systematic in one-third of the centers and guided by risk factors in the other centers. Antibiotic prophylaxis was strictly intraoperative in only 7 centers (44%). Antifungal prophylaxis targeting high-risk LT recipients was administered in 15 centers (93%). Intraoperative coagulation assessment was based on standard coagulation tests in 8 centers (50%), on viscoelastic assays in 4 centers (25%), and both methods in 4 centers (25%). Hemodynamic monitoring practices greatly varied between centers.Concerning immunosuppression, molecules and dosages were heterogeneous. Aspirin was systematically administered in one-third of cases (6 centers; 37.5%). Of the 21 recommendations tested, the concordance rate was 100% for 3 recommendations and <50% for 7 recommendations. CONCLUSIONS Our study precisely describes French practices regarding LT in perioperative care and highlights the paucity of data in this setting, leading to very weak recommendations that are poorly followed in LT centers.
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Affiliation(s)
- Pauline Devauchelle
- Department of Anaesthesiology and Critical Care, Hôpital Beaujon, AP-HP, Clichy, France
| | - Anne Bignon
- CHU Lille, Surgical Critical Care and Hepatic Transplant Unit, Department of Anesthesia Critical Care and Perioperative Medicine, Lille, France
| | - Isaure Breteau
- Department of Anesthesia and Surgical Intensive Care Unit, Tours University Hospital, Tours, France
| | - Mylène Defaye
- Department of Anaesthesia and Intensive Care, Bordeaux University Hospital, Pessac, France
| | - Laurianne Degravi
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Montpellier, France
| | - Cyrielle Despres
- Department of Anaesthesia and Intensive Care, Minjoz Hospital, Besançon University Hospital, Besançon, France
| | - Alexandre Godon
- Department of Anaesthesia and Intensive Care, University of Grenoble Alpes, Grenoble Alpes University Hospital, Grenoble, France
| | - Renaud Guérin
- Service De Réanimation Adultes, Unité de Soins Continus et Unité de Transplantation Hépatique, pôle MPO, CHU Estaing, Clermont-Ferrand, France
| | - Laurence Lavayssiere
- Intensive Care Unit, Department of Transplantation, Rangueil University Hospital, Toulouse, France
| | - Benjamin Lebas
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Axelle Maurice
- Département d'Anesthésie réanimation chirurgicale, CHU Pontchaillou, Rennes, France
| | - Clément Monet
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Montpellier, France
| | - Antoine Monsel
- Sorbonne Université-INSERM UMRS_959, Immunology-Immunopathology-Immunotherapy, Paris, France
- Biotherapy (CIC-BTi), La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Paris, France
- UMRS-938, Research Center of Saint-Antoine (CRSA), Sorbonne University, Paris, France
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Laurent Reydellet
- Service d'Anesthésie-Réanimation, Réanimation Polyvalente et Pathologie du Foie, APHM, C.H.U. Timone, Marseille, France
| | - Stéphanie Roullet
- Département d'Anesthésie Réanimation, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITH U1176, Le Kremlin-Bicêtre, France
| | - Romain Rozier
- Department of Anesthesia and Intensive Care, University of Cöte d'Azur, University Hospital Archer 2, Nice, France
| | - Céline Guichon
- Service d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Université de Paris, Hôpital Beaujon, AP-HP, Clichy, France
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7
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Ververeli CL, Dimitroglou Y, Soulaidopoulos S, Cholongitas E, Aggeli C, Tsioufis K, Tousoulis D. Cardiac Remodeling and Arrhythmic Burden in Pre-Transplant Cirrhotic Patients: Pathophysiological Mechanisms and Management Strategies. Biomedicines 2025; 13:812. [PMID: 40299454 PMCID: PMC12025098 DOI: 10.3390/biomedicines13040812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2025] [Revised: 03/22/2025] [Accepted: 03/25/2025] [Indexed: 04/30/2025] Open
Abstract
Background: Chronic liver disease (CLD) and cirrhosis contribute to approximately 2 million deaths annually, with primary causes including alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and chronic hepatitis B and C infections. Among these, MASLD has emerged as a significant global health concern, closely linked to metabolic disorders and a leading cause of liver failure and transplantation. Objective: This review aims to highlight the interplay between cirrhosis and cardiac dysfunction, emphasizing the pathophysiology, diagnostic criteria, and management of cirrhotic cardiomyopathy (CCM). Methods: A comprehensive literature review was conducted to evaluate the hemodynamic and structural cardiac alterations in cirrhosis. Results: Cirrhosis leads to portal hypertension and systemic inflammation, contributing to CCM, which manifests as subclinical cardiac dysfunction, impaired contractility, and electrophysiological abnormalities. Structural changes, such as increased left ventricular mass, myocardial fibrosis, and ion channel dysfunction, further impair cardiac function. Vasodilation in the splanchnic circulation reduces peripheral resistance, triggering compensatory tachycardia, while the activation of the renin-angiotensin-aldosterone system (RAAS) promotes fluid retention and increases cardiac preload. Chronic inflammation and endotoxemia exacerbate myocardial dysfunction. The 2005 World Congress of Gastroenterology (WCG) and the 2019 Cirrhotic Cardiomyopathy Consortium (CCC) criteria provide updated diagnostic frameworks that incorporate global longitudinal strain (GLS) and tissue Doppler imaging (TDI). Prolonged QT intervals and arrhythmias are frequently observed. Managing heart failure in cirrhotic patients remains complex due to intolerance to afterload-reducing agents, and beta-blockers require careful use due to potential systemic hypotension. The interaction between CCM and major interventions, such as transjugular intrahepatic portosystemic shunt (TIPS) and orthotopic liver transplantation (OLT), highlights the critical need for thorough preoperative cardiac evaluation and vigilant postoperative monitoring. Conclusions: CCM is a frequently underdiagnosed yet significant complication of cirrhosis, impacting prognosis, particularly post-liver transplantation. Early identification using echocardiography and thorough evaluations of arrhythmia risk in cirrhotic patients are critical for optimizing management strategies. Future research should focus on targeted therapeutic approaches to mitigate the cardiac burden in cirrhotic patients and improve clinical outcomes.
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Affiliation(s)
- Charilila-Loukia Ververeli
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Yannis Dimitroglou
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Stergios Soulaidopoulos
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Evangelos Cholongitas
- 1st Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Constantina Aggeli
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Dimitris Tousoulis
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
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8
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Poyekar S, Kapoor D. Pre-Liver Transplant Cardiac Evaluation-Demystifying the Heart Under Stress or Unclogging the Coronaries? J Clin Exp Hepatol 2025; 15:102448. [PMID: 40177698 PMCID: PMC11959372 DOI: 10.1016/j.jceh.2024.102448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 10/21/2024] [Indexed: 04/05/2025] Open
Affiliation(s)
- Samriddhi Poyekar
- Associate Consultant, Transplant Medicine, Yashoda Hospital, Secunderabad, India
| | - Dharmesh Kapoor
- Senior Consultant- Hepatologist, Yashoda Hospital, Secunderabad, India
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9
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Gunt C, Çekmen N. Perioperative Variation of Plasma Copeptin and Its Association With Vasopressor Need During Liver Transplantation. Transplant Proc 2025; 57:277-283. [PMID: 39848860 DOI: 10.1016/j.transproceed.2024.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 10/25/2024] [Accepted: 11/19/2024] [Indexed: 01/25/2025]
Abstract
BACKGROUND Vasopressor usage during liver transplant is related to decreased hepatic flow, graft failure, and mortality. We measured plasma Copeptin levels in liver transplant patients based on vasopressor requirements. We hypothesize that preoperative plasma copeptin measurement helps predict the vasopressor infusion requirement during liver transplantation in preoperative evaluation. METHODS The plasma Copeptin of 40 patients was measured 5 times: before the operation, 15 minutes before and after reperfusion, and postoperative 12th and 24th hours. Patients were categorized into 2 groups based on vasopressor infusion for comparison. RESULTS There was a statistically significant rise in median serum Copeptin concentration between the preoperative phase and before reperfusion (11.2 [7.3-20.9] vs 178.5 [121.5-243.0], P < .001), as well as a statistically substantial decline between after reperfusion and postoperative 12th hours (190.6 [127-276.3] vs 74.7 [42.0-124.9], P < .001). The vasopressor-taking group had significantly higher plasma copeptin at postoperative 12th hours (96.6 [71.4-191.7] vs 55.0 [31.8-82.5], P = .030) and 24th (133.7 [72.2-175.5] vs 51.1 [24.8-85.8], P = .037). A tendency above 11.85 pmol/L of plasma Copeptine level was observed between increasing preoperative plasma Copeptin and the odds of vasopressor use. CONCLUSION High preoperative plasma Copeptin levels may be an indicator of vasopressor need during liver transplantation. Further studies with more samples, including a higher range of preoperative plasma Copeptin levels, are required to provide more generalizable findings and to determine thresholds applicable to LT candidates.
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Affiliation(s)
- Ceren Gunt
- Ankara Güven Hospital, Department of Anaesthesiology and Reanimation Çankaya/Ankara, Turkey.
| | - Nedim Çekmen
- Nişantaşı University Health Services Vocational School, Department of Anesthesia, Turkey
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10
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Singh SA, Prakash K, Kajal K, Loganathan S, K N, Subramanian R, Singh A, Choudhary NS, Mukherjee A, Viswanathan Premkumar G, Sindwani G, Ranade S, Malleeswaran SK, Raghu A, Mathiyazhagan R, Venkatachalapathy S, Pant D, Srivastava P, Kumar L, Vohra V, Rajkumar A, Narsimhan G, Goel A, Aggarwal V, Kumar A, Panackel C. LTSI Consensus Guidelines: Preoperative Cardiac Evaluation in Adult Liver Transplant Recipients. J Clin Exp Hepatol 2025; 15:102419. [PMID: 40177699 PMCID: PMC11959373 DOI: 10.1016/j.jceh.2024.102419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 09/27/2024] [Indexed: 01/03/2025] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among LT candidates and accounts for up to 40% of the overall mortality within one month. It is influenced by traditional and nontraditional risk factors related to end-stage liver disease. A large proportion of CLD patients have underlying cardiovascular disease (CVD) especially if the etiology is metabolic associated steatohepatitis. Despite the large number of liver transplantations being conducted in India, there is a lack of an evidence-based guidelines for screening of CVD in this patient population. This consensus statement from Liver Transplant Society of India (LTSI) is the first attempt for developing an evidence-based document on preoperative cardiac evaluation from India. A task force consisting of transplant-anesthesiologists, transplant hepatologists, liver transplant surgeon and cardiologists from high volume centres was formed which reviewed the existing evidence and literature and formulated graded recommendations. The document focuses on identification of underlying cardiac pathologies, risk stratification and optimisation of modifiable cardiac diseases. Implementation of best practices and optimal strategies should be encouraged to improve cardiovascular outcomes in these populations.
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Affiliation(s)
- Shweta A. Singh
- Department of Anaesthesia and Critical Care - Center for Liver & Biliary Sciences (CLBS), Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
| | - Kelika Prakash
- Department of Anaesthesiology, Pain Medicine & Critical Care AIIMS, New Delhi, India
| | - Kamal Kajal
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sekar Loganathan
- Department of Anesthesiology, All India Institute of Medical Sciences Kalyani, West Bengal, India
| | - Nandakumar K
- GI/Liver/Renal Intensive Care, Liver & Renal Intensive Care, Apollo Main Hospitals, Chennai, India
| | | | - Anil Singh
- Liver Transplant Anaesthesia & Critical Care, Nanavati Max Super Speciality Hospital, Mumbai, India
| | - Narendra S Choudhary
- Institute of Liver Transplantation & Regenerative Medicine, Medanta the Medicity, Gurugram, India
| | | | | | | | - Sharmila Ranade
- Liver Transplant Anaesthesia, Kokilaben Dhirubhai Ambani Hospital & Medical Research Centre, Andheri East Mumbai, India
| | - Selva K. Malleeswaran
- Department of Liver Anesthesia and Critical Care, Gleneagles Hospitals, Chennai, India
| | - Arun Raghu
- Anaesthesia & Transplant Anaesthesia, Gleneagles BGS Hospital, Bengaluru, India
| | | | | | - Deepanjali Pant
- Institute of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital New Delhi, India
| | - Piyush Srivastava
- Department of Liver Transplant Anaesthesia & Critical Care, Fortis Hospiital, Noida, India
| | - Lakshmi Kumar
- Department of Anaesthesiology & Critical Care, Amrita Institute of Medical Sciences, Kochi, India
| | - Vijay Vohra
- Liver Transplant, GI Anaesthesia & Intensive Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Akila Rajkumar
- Liver Intensive Care and Anaesthesia, Dr.Rela Institute & Medical Center, Chennai, India
| | | | - Anupam Goel
- Max Super Speciality Hospital (MSSH) Saket, New Delhi, India
| | - Vinayak Aggarwal
- Clinical Cardiology & Advance Cardiac Imaging, Fortis Memorial Research Institute(FMRI), Gurgaon, India
| | - Ashok Kumar
- Intereventional Cardiologist Advance Heart Failure Specialist, Dr.Rela Institute & Medical Center, Chennai, India
| | - Charles Panackel
- Hepatology & Liver Transplsant, Aster Integrated Liver Care, Kochi, India
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11
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De Gasperi A, Petrò L, Cerutti E. Liver Transplantation and the Older Adults Candidate: Perioperative Considerations. Clin Geriatr Med 2025; 41:65-81. [PMID: 39551542 DOI: 10.1016/j.cger.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2024]
Abstract
Pioneered by Thomas Starzl in the early 1970s, liver transplant (LT) is nowadays often considered a final intervention and standard of care to cure many forms of acute and chronic end-stage liver diseases. Started in recipients younger than 60 years old, LT indications are now much broader, and at least, one-fifth of the candidates are older than 65 years. Problems associated with ageing and frailty in LT recipients and their impact on the entire perioperative course are discussed according to a modern anesthesiological perspective and the anesthesiologist covering the role of the perioperative (transplant) physician.
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Affiliation(s)
| | - Laura Petrò
- ANRI1 - Emergency and Intensive Care, ASST Ospedale Giovanni XXIII, Bergamo, Italy; ASST Papa Giovanni XXII, Piazza MSO 1, 24100 Bergamo, Italy
| | - Elisabetta Cerutti
- Anestesia e Rianimazione dei Trapianti e Chirurgia Maggiore, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60020, Ancona, Italy; Azienda Ospedaliero Universitaria "Ospedali Riuniti", Via Conca 71, 60020, Ancona, Italy
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12
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Samuel D, De Martin E, Berg T, Berenguer M, Burra P, Fondevila C, Heimbach JK, Pageaux GP, Sanchez-Fueyo A, Toso C. EASL Clinical Practice Guidelines on liver transplantation. J Hepatol 2024; 81:1040-1086. [PMID: 39487043 DOI: 10.1016/j.jhep.2024.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 11/04/2024]
Abstract
Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.
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13
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Harinstein ME, Gandolfo C, Gruttadauria S, Accardo C, Crespo G, VanWagner LB, Humar A. Cardiovascular disease assessment and management in liver transplantation. Eur Heart J 2024; 45:4399-4413. [PMID: 39152050 DOI: 10.1093/eurheartj/ehae502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/21/2024] [Accepted: 07/25/2024] [Indexed: 08/19/2024] Open
Abstract
The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.
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Affiliation(s)
- Matthew E Harinstein
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caterina Gandolfo
- Unit of Interventional Cardiology, Department of Cardiothoracic Surgery, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Caterina Accardo
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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14
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Chanan EL, Wagener G, Whitlock EL, Berger JC, McAdams-DeMarco MA, Yeh JS, Nunnally ME. Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review. Transplantation 2024; 108:e346-e356. [PMID: 38557579 PMCID: PMC11442682 DOI: 10.1097/tp.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.
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Affiliation(s)
- Emily L Chanan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth L Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA
| | - Jonathan C Berger
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Joseph S Yeh
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
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15
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Tandon R, Agakishiev D, Freese RL, Thompson J, Nijjar PS. Detection of Coronary Artery Disease With Coronary Computed Tomography Angiography and Stress Testing in Candidates for Liver Transplant. Am J Cardiol 2024; 230:14-21. [PMID: 39197736 DOI: 10.1016/j.amjcard.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 09/01/2024]
Abstract
Cardiac complications are the leading cause of morbidity and mortality in recipients of liver transplant (LT). Previous guidelines recommended stress testing to exclude coronary artery disease (CAD), although recent guidelines recommend coronary computed tomography angiography (CCTA). We aimed to assess the prevalence and predictors of CAD on CCTA and compare CCTA with stress testing in consecutive adult candidates for LT who underwent CAD noninvasive assessment between 2020 and 2023. Patients who underwent a stress test between January and December 2020 formed the stress cohort, and patients who underwent CCTA between January 2021 and September 2023 formed the CCTA cohort. There were 141 patients in the stress test cohort and 269 patients in the CCTA cohort. Stress test results were nondiagnostic or inconclusive in 18 patients (12.8%) whereas CCTA was nondiagnostic in 6 patients (2.2%). In patients evaluated with CCTA, mean coronary artery calcium (CAC) score was 332 ± 716 AU, with moderate or greater (>50%) stenosis in 33 patients (12.3%). New CAD was diagnosed in 158 patients (58.7%) using CCTA and in 5 patients (3.5%) using stress tests. Clinically actionable CAD (coronary artery calcium >100) on CCTA was present in 96 patients (35.7%). The number of CAD risk factors was associated with the presence of CAD on CCTA. In conclusion, there was a great burden of CAD, mainly nonobstructive, in a large cohort of candidates for LT who underwent CAD testing over a 4-year period. The current recommended risk-based evaluation of candidates for LT using CCTA as a first-line test was feasible and effective. Diagnosis of clinically actionable CAD on CCTA provides a vast opportunity for optimizing cardiac care in candidates for and recipients of LT.
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Affiliation(s)
- Rishabh Tandon
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School
| | | | - Rebecca L Freese
- Clinical and Translational Science Institute, Biostatistical Design and Analysis Center
| | - Julie Thompson
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Prabhjot S Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School.
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16
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Brahmania M, Kuo A, Tapper EB, Volk ML, Vittorio JM, Ghabril M, Morgan TR, Kanwal F, Parikh ND, Martin P, Mehta S, Winder GS, Im GY, Goldberg D, Lai JC, Duarte-Rojo A, Paredes AH, Patel AA, Sahota A, McElroy LM, Thomas C, Wall AE, Malinis M, Aslam S, Simonetto DA, Ufere NN, Ramakrishnan S, Flynn MM, Ibrahim Y, Asrani SK, Serper M. Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases. Hepatology 2024; 80:742-753. [PMID: 38536021 DOI: 10.1097/hep.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 05/19/2024]
Abstract
The liver transplantation (LT) evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into 4 phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care, and social work selected the final set. Candidate patient-reported experience measures spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures, and 10 were outcome measures that focused on elements not typically measured in routine care. Among the patient-reported experience measures, candidates of LT rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among candidates of LT. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local quality improvement initiatives to improve access and quality of care.
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Affiliation(s)
- Mayur Brahmania
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Kuo
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael L Volk
- Department of Medicine, Baylor Scott and White Health, Temple, Texas, USA
| | - Jennifer M Vittorio
- Division of Pediatric Gastroenterology, Department of Medicine, New York University (NYU) Langone Health, New York, New York, USA
| | - Marwan Ghabril
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy R Morgan
- Division of Gastroenterology, Department of Medicine, University of California, Irvine, California, USA
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Fasiha Kanwal
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Martin
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Shivang Mehta
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Gene Y Im
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angelo H Paredes
- Division of Gastroenterology, Department of Medicine, University of San Antonio, San Antonio, Texas, USA
| | - Arpan A Patel
- Division of Gastroenterology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Amandeep Sahota
- Department of Transplant Hepatology, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Lisa M McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charlie Thomas
- Banner University Medical Center Phoenix Transplant Program, Phoenix, Arizona, USA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nneka N Ufere
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mary Margaret Flynn
- Division of Gastroenterology, Department of Medicine, University of Massachusetts, Boston, Massachusetts, USA
| | | | - Sumeet K Asrani
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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17
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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Abdelhameed A, Bhangu H, Feng J, Li F, Hu X, Patel P, Yang L, Tao C. Deep Learning-Based Prediction Modeling of Major Adverse Cardiovascular Events After Liver Transplantation. MAYO CLINIC PROCEEDINGS. DIGITAL HEALTH 2024; 2:221-230. [PMID: 38993485 PMCID: PMC11238640 DOI: 10.1016/j.mcpdig.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Objective To validate deep learning models' ability to predict post-transplantation major adverse cardiovascular events (MACE) in patients undergoing liver transplantation (LT). Patients and Methods We used data from Optum's de-identified Clinformatics Data Mart Database to identify liver transplant recipients between January 2007 and March 2020. To predict post-transplantation MACE risk, we considered patients' demographics characteristics, diagnoses, medications, and procedural data recorded back to 3 years before the LT procedure date (index date). MACE is predicted using the bidirectional gated recurrent units (BiGRU) deep learning model in different prediction interval lengths up to 5 years after the index date. In total, 18,304 liver transplant recipients (mean age, 57.4 years [SD, 12.76]; 7158 [39.1%] women) were used to develop and test the deep learning model's performance against other baseline machine learning models. Models were optimized using 5-fold cross-validation on 80% of the cohort, and model performance was evaluated on the remaining 20% using the area under the receiver operating characteristic curve (AUC-ROC) and the area under the precision-recall curve (AUC-PR). Results Using different prediction intervals after the index date, the top-performing model was the deep learning model, BiGRU, and achieved an AUC-ROC of 0.841 (95% CI, 0.822-0.862) and AUC-PR of 0.578 (95% CI, 0.537-0.621) for a 30-day prediction interval after LT. Conclusion Using longitudinal claims data, deep learning models can efficiently predict MACE after LT, assisting clinicians in identifying high-risk candidates for further risk stratification or other management strategies to improve transplant outcomes based on important features identified by the model.
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Affiliation(s)
- Ahmed Abdelhameed
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Jacksonville, FL
| | - Harpreet Bhangu
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Jingna Feng
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Jacksonville, FL
| | - Fang Li
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Jacksonville, FL
| | - Xinyue Hu
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Jacksonville, FL
| | - Parag Patel
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Liu Yang
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Cui Tao
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Jacksonville, FL
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19
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Sampaio Rodrigues T, Narendren A, Cailes B, Lim RP, Weinberg L, Testro A, Majumdar A, Sinclair M, Farouque O, Koshy AN. Enhancing pre-transplant cardiac assessment: Validation and utility of the CAD-LT score with CCTA in liver transplant candidates. Int J Cardiol 2024; 403:131895. [PMID: 38395260 DOI: 10.1016/j.ijcard.2024.131895] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/08/2024] [Accepted: 02/18/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) is increasingly being used in the preoperative workup for liver transplantation (LT). We sought to assess the utility of integrating CCTA with the novel CAD-LT (Coronary Artery Disease in Liver Transplantation) score and its impact on reducing the need for invasive coronary angiography prior to LT. METHODS We conducted a retrospective cohort study of consecutive patients (age ≥ 18 years) who underwent CCTA for LT workup between 2011 and 2018 at the Victorian Liver Transplant Unit, Melbourne, Australia. CAD-LT scores, a traditional risk factor-based criteria, were calculated, and patients stratified as low-, intermediate- or high-risk. RESULTS Overall, 229 patients underwent CCTA. The mean age was 66 ± 5 years (82% male) with a modest-to-high risk factor burden (diabetes, 53%; hypertension, 46%; current or former smoker, 62%). The mean CAD-LT score of our cohort was 12.4 ± 4.0. No patients were classified as low-risk, 49 patients (21.4%) were deemed intermediate-risk and 180 patients (78.6%) were deemed high-risk. A high CAD-LT score (≥ 9) showed high sensitivity (95.3% [95% CI 86-98%]) and modest specificity (27.8% [95% CI 21-35%]) for the detection of obstructive coronary artery disease on CCTA, with a negative predictive value of 94%. Following multidisciplinary discussions, only 41 patients (18%) of patients proceeded to ICA of which 27% received percutaneous coronary intervention. CONCLUSIONS The use of CCTA in patients deemed intermediate- to high-risk by the CAD-LT score has the potential to reduce the need for invasive coronary angiography in patients undergoing LT workup.
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Affiliation(s)
- Thalys Sampaio Rodrigues
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia
| | - Ahthavan Narendren
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Cardiology, Northern Health, Melbourne, VIC, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia
| | - Ruth P Lim
- Department of Radiology, The University of Melbourne, VIC, Australia; Department of Radiology, Austin Health, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Medicine, The University of Melbourne, VIC, Australia; Department of Anaesthesiology, The University of Melbourne, VIC, Australia
| | - Adam Testro
- Department of Medicine, The University of Melbourne, VIC, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - Avik Majumdar
- Department of Medicine, The University of Melbourne, VIC, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - Marie Sinclair
- Department of Medicine, The University of Melbourne, VIC, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia.
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20
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Müller M, Grasshoff C. [The Role of the Anaesthesiologist in Liver Transplantation - Preoperative Evaluation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:283-295. [PMID: 38759684 DOI: 10.1055/a-2152-7350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.
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21
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Martinez-Perez S, McCluskey SA, Davierwala PM, Kalra S, Nguyen E, Bhat M, Borosz C, Luzzi C, Jaeckel E, Neethling E. Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions. J Cardiothorac Vasc Anesth 2024; 38:1015-1030. [PMID: 38185566 DOI: 10.1053/j.jvca.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024]
Abstract
Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.
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Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre Toronto, General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sanjog Kalra
- Division of Cardiology, Interventional Cardiology Section, Peter Munk Cardiac Center Toronto General Hospital, University Health Network and Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elsie Nguyen
- Department of Medical Imaging, Cardiothoracic Imaging Division Lead, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Gastroenterology, Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Borosz
- Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Carla Luzzi
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Department of Gastroenterology, Ajmera Transplant Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Elmari Neethling
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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22
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Lai Q, Caimano M, Canale F, Birtolo LI, Ferri F, Corradini SG, Mancone M, Marrone G, Pedicino D, Rossi M, Vernole E, Pompili M, Biolato M. The role of echocardiographic assessment for the risk of adverse events in liver transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100838. [PMID: 38417399 DOI: 10.1016/j.trre.2024.100838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND & AIMS Echocardiographic findings may provide valuable information about the cardiac conditions in cirrhotic patients waiting for liver transplantation (LT). However, data on the ability of the different echocardiographic parameters to predict post-transplant risk of mortality are scarce and heterogeneous. This systematic review evaluates the role of different echocardiographic features as predictors of post-LT mortality. A meta-analysis was also performed according to the observed results. METHODS A systematic review was conducted according to PRISMA guidelines. Medline (PubMed) database was searched through February 2023 for relevant published original articles reporting the prognostic value of echocardiographic findings associated with outcomes of adult LT recipients. The risk of bias in included articles was assessed using ROBINS-E tool. Methodological quality varied from low to high across the risk of bias domains. RESULTS Twenty-three studies were identified after the selection process; ten were enrollable for the meta-analyses. According to the results observed, the E/A ratio fashioned as a continuous value (HR = 0.43, 95%CI = 0.25-0.76; P = 0.003), and tricuspid regurgitation (HR = 2.36, 95%CI = 1.05-5.31; P = 0.04) were relevant predicting variables for post-LT death. Other echocardiographic findings failed to merge with statistical relevance. CONCLUSION Tricuspid regurgitation and left ventricular diastolic dysfunction play a role in the prediction of post-LT death. More studies are needed to clarify further the impact of these echocardiographic features in the transplantation setting.
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Affiliation(s)
- Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy.
| | - Miriam Caimano
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Canale
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, AOU Umberto I Policlinico of Rome, Rome, Italy
| | - Stefano Ginanni Corradini
- Department of Translational and Precision Medicine, Sapienza University of Rome, AOU Umberto I Policlinico of Rome, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Giuseppe Marrone
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Daniela Pedicino
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Elisabetta Vernole
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Maurizio Pompili
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Marco Biolato
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
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23
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Sampaio Rodrigues T, Koshy AN, Gow PJ, Weinberg L, Cailes B, Testro A, Smith G, Lim HS, Teh AW, Lim RP, Farouque O. Atherosclerosis on CT coronary angiography and the risk of long-term cardiovascular events after liver transplantation. Liver Transpl 2024; 30:182-191. [PMID: 37432891 DOI: 10.1097/lvt.0000000000000215] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
Computed tomography coronary angiography (CTCA) is increasingly utilized for preoperative risk stratification before liver transplantation (LT). We sought to assess the predictors of advanced atherosclerosis on CTCA using the recently developed Coronary Artery Disease-Reporting and Data System (CAD-RADS) score and its impact on the prediction of long-term major adverse cardiovascular events (MACE) following LT. We conducted a retrospective cohort study of consecutive patients who underwent CTCA for LT work-up between 2011 and 2018. Advanced atherosclerosis was defined as coronary artery calcium scores > 400 or CAD-RADS score ≥ 3 (≥50% coronary artery stenosis). MACE was defined as myocardial infarction, heart failure, stroke, or resuscitated cardiac arrest. Overall, 229 patients underwent CTCA (mean age 66 ± 5 y, 82% male). Of these, 157 (68.5%) proceeded with LT. The leading etiology of cirrhosis was hepatitis (47%), and 53% of patients had diabetes before transplant. On adjusted analysis, male sex (OR 4.6, 95% CI 1.5-13.8, p = 0.006), diabetes (OR 2.2, 95% CI 1.2-4.2, p = 0.01) and dyslipidemia (OR 3.1, 95% CI 1.3-6.9, p = 0.005) were predictors of advanced atherosclerosis on CTCA. Thirty-two patients (20%) experienced MACE. At a median follow-up of 4 years, CAD-RADS ≥ 3, but not coronary artery calcium scores, was associated with a heightened risk of MACE (HR 5.8, 95% CI 1.6-20.6, p = 0.006). Based on CTCA results, 71 patients (31%) commenced statin therapy which was associated with a lower risk of all-cause mortality (HR 0.48, 95% CI 0.24-0.97, p = 0.04). The standardized CAD-RADS classification on CTCA predicted the occurrence of cardiovascular outcomes following LT, with a potential to increase the utilization of preventive cardiovascular therapies.
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Affiliation(s)
- Thalys Sampaio Rodrigues
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Paul J Gow
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Anesthesiology, Austin Health, Melbourne, Victoria, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Adam Testro
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Gerard Smith
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Ruth P Lim
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
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24
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Kuo SZ, Tincopa M. Predicting cardiovascular events after liver transplant: Is CT coronary angiography the noninvasive test we have been looking for? Liver Transpl 2024; 30:117-118. [PMID: 37773041 DOI: 10.1097/lvt.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Selena Z Kuo
- Division of Gastroenterology & Hepatology, University of California at San Diego, La Jolla, California, USA
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25
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Puri P, Malik S. Liver Transplantation: Contraindication and Ineligibility. J Clin Exp Hepatol 2023; 13:1116-1129. [PMID: 37975058 PMCID: PMC10643298 DOI: 10.1016/j.jceh.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/14/2023] [Indexed: 11/19/2023] Open
Abstract
Liver transplantation (LT) is a life-saving therapeutic modality for patients with various advanced liver diseases. It is crucial to identify that the patient's illness is sufficiently advanced and unlikely to improve with medical management to justify the need for transplantation. At the same time, it is crucial to identify patients with comorbidities and far advanced disease that would result in an unacceptable outcome after LT. Specific care also is required before deciding on LT in the elderly, acute on chronic liver disease, patients with comorbidities, and hepatocellular carcinoma. Transplantation needs to be timed appropriately to avoid unnecessary LT and ensure that the decision is not left too late to avoid losing the patient without a transplant. Also, important is the decision as to when not to transplant. The current review explores some of these issues of contraindications and ineligibility for LT.
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver and Digestive Diseases Institute, Fortis Escorts Hospital, New Delhi 110025, India
| | - Sarthak Malik
- Department of Gastroenterology, Manipal Hospital, Dwarka, New Delhi 110075, India
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26
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Hughes DL, Pan J, Answine AR, Sonnenday CJ, Waits SA, Kumar SS, Menees DS, Wanamaker B, Bhave NM, Tincopa MA, Fontana RJ, Sharma P. Positron emission tomography myocardial perfusion imaging (PET MPI) findings predictive of post-liver transplant major adverse cardiac events. Liver Transpl 2023; 29:970-978. [PMID: 36879556 DOI: 10.1097/lvt.0000000000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023]
Abstract
Positron emission tomography myocardial perfusion imaging (PET MPI) is a noninvasive diagnostic test capable of detecting coronary artery disease, structural heart disease, and myocardial flow reserve (MFR). We aimed to determine the prognostic utility of PET MPI to predict post-liver transplant (LT) major adverse cardiac events (MACE). Among the 215 LT candidates that completed PET MPI between 2015 and 2020, 84 underwent LT and had 4 biomarker variables of clinical interest on pre-LT PET MPI (summed stress and difference scores, resting left ventricular ejection fraction, global MFR). Post-LT MACE were defined as acute coronary syndrome, heart failure, sustained arrhythmia, or cardiac arrest within the first 12 months post-LT. Cox regression models were constructed to determine associations between PET MPI variable/s and post-LT MACE. The median LT recipient age was 58 years, 71% were male, 49% had NAFLD, 63% reported prior smoking, 51% had hypertension, and 38% had diabetes mellitus. A total of 20 MACE occurred in 16 patients (19%) at a median of 61.5 days post-LT. One-year survival of MACE patients was significantly lower than those without MACE (54% vs. 98%, p =0.001). On multivariate analysis, reduced global MFR ≤1.38 was associated with a higher risk of MACE [HR=3.42 (1.23-9.47), p =0.019], and every % reduction in left ventricular ejection fraction was associated with an 8.6% higher risk of MACE [HR=0.92 (0.86-0.98), p =0.012]. Nearly 20% of LT recipients experienced MACE within the first 12 months of LT. Reduced global MFR and reduced resting left ventricular ejection fraction on PET MPI among LT candidates were associated with increased risk of post-LT MACE. Awareness of these PET-MPI parameters may help improve cardiac risk stratification of LT candidates if confirmed in future studies.
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Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Jason Pan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Adeline R Answine
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel S Menees
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brett Wanamaker
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole M Bhave
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica A Tincopa
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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Annie FH, Belcher AM, Manivannan PKR, Elashery AR. Impact of TAVR on patients with severe aortic stenosis and liver cirrhosis. Am J Physiol Heart Circ Physiol 2023; 325:H539-H544. [PMID: 37477691 PMCID: PMC10538975 DOI: 10.1152/ajpheart.00342.2023] [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: 06/09/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/22/2023]
Abstract
We sought to assess the impact of transcatheter aortic valve replacement (TAVR) on patients that have both severe aortic stenosis (SAS) and liver cirrhosis on mortality at 365 days after index event. We identified 19,210 patients that met inclusion criteria using the TriNetX database, consisting of data from 58 large healthcare organizations collected between 1 January 2010 and 24 February 2022. Of those patients, 1,283 (3.2%) had SAS with liver cirrhosis that had a TAVR, and 19,210 (96.8%) had SAS with liver cirrhosis that did not have a TAVR. We analyzed the data to compare all-cause mortality at 365 days using the TriNetX web platform. In addition, we conducted propensity score matching (PSM) to reduce the effects of confounders between the two groups. Patients with SAS and liver cirrhosis that had a TAVR were older (72.4 ± 9.7 vs. 68.0 ± 11.8, P < 0.001), and they had higher rates of heart failure (71.2 vs. 34.5%, P < 0.001), coronary artery disease (72.0 vs. 31.2%, P < 0.001), diabetes (52.5 vs. 41.2%, P < 0.001), and chronic kidney disease (43.8 vs. 30.1%, P < 0.001) compared with patients with SAS and liver cirrhosis without TAVR. PSM created two well-matched cohorts of 1,269 patients each. The TAVR group had a lower mortality rate compared with the no TAVR group (22.5 vs. 34.8%, P < 0.0001) at 365 days. This was confirmed using a log-rank test. Given these data, it appears that there is a mortality benefit associated with TAVR in patients with SAS and liver cirrhosis.NEW & NOTEWORTHY Risk calculators used to predict unfavorable surgical outcomes could flag a patient as ineligible for transcatheter aortic valve replacement (TAVR) based on the presence of liver cirrhosis. Our data analysis suggests that performing a TAVR to treat severe aortic stenosis in patients with liver cirrhosis could decrease their mortality risk as opposed to not performing a TAVR. Careful consideration should be given to this patient population to ensure the best quality of life and long-term outcome.
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Affiliation(s)
- Frank H Annie
- Department of Cardiology, CAMC Health Education and Research Institute, Charleston, West Virginia, United States
| | - Adam M Belcher
- Department of Cardiology, CAMC Health Education and Research Institute, Charleston, West Virginia, United States
| | | | - Ahmad Ramy Elashery
- CAMC Vascular Center of Excellence, Charleston Area Medical Center, Charleston, West Virginia, United States
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De Gasperi A, Petrò L, Cerutti E. Liver Transplantation and the Elderly Candidate: Perioperative Considerations. Anesthesiol Clin 2023; 41:595-611. [PMID: 37516497 DOI: 10.1016/j.anclin.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Pioneered by Thomas Starzl in the early 1970s, liver transplant (LT) is nowadays often considered a final intervention and standard of care to cure many forms of acute and chronic end-stage liver diseases. Started in recipients younger than 60 years old, LT indications are now much broader, and at least, one-fifth of the candidates are older than 65 years. Problems associated with ageing and frailty in LT recipients and their impact on the entire perioperative course are discussed according to a modern anesthesiological perspective and the anesthesiologist covering the role of the perioperative (transplant) physician.
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Affiliation(s)
| | - Laura Petrò
- ANRI1 - Emergency and Intensive Care, ASST Ospedale Giovanni XXIII, Bergamo, Italy; ASST Papa Giovanni XXII, Piazza MSO 1, 24100 Bergamo, Italy
| | - Elisabetta Cerutti
- Anestesia e Rianimazione dei Trapianti e Chirurgia Maggiore, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60020, Ancona, Italy; Azienda Ospedaliero Universitaria "Ospedali Riuniti", Via Conca 71, 60020, Ancona, Italy
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29
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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30
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Harrington CR, Levy P, Cabrera E, Gao J, Gregory DL, Padilla C, Crespo G, VanWagner LB. Evolution of pretransplant cardiac risk factor burden and major adverse cardiovascular events in liver transplant recipients over time. Liver Transpl 2023; 29:581-590. [PMID: 36724875 PMCID: PMC10192050 DOI: 10.1097/lvt.0000000000000013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/26/2022] [Indexed: 02/03/2023]
Abstract
Major adverse cardiovascular events (MACEs) are the leading cause of early (<1 y) complications after liver transplantation (LT). NASH, the leading indication for waitlisting for LT, is associated with high cardiac risk factor burden. The contemporary prevalence and temporal trends in pretransplant cardiac risk factor burden and post-LT MACE among LT recipients (LTRs) with and without NASH are unknown. The aim of this study was to evaluate (1) the evolution of post-LT cardiac risk factors in LTRs over time and (2) post-LT MACE over time, stratified by NASH status. This is a retrospective cohort of 1775 adult LTRs at a single transplant center (2003-2020). MACE was defined as death or hospitalization from myocardial infarction, revascularization, stroke, heart failure during the first post-LT year. Between 2003 and 2020, there was a significant increase in pre-LT NASH ( ptrend <0.05). There was also a significant increase in pre-LT obesity, atherosclerotic cardiovascular (CV) disease, and older age (≥65 y old) ( ptrend <0.05 for all). There was no significant change in the proportion of LTRs with diabetes, chronic kidney disease, or heart failure. Unexpectedly, there were no changes in the rate of post-LT MACE over the study period (-0.1% per year, ptrend =0.44). The lack of change in MACE despite an increase in CV risk factor prevalence may reflect advancement in the identification and management of CV risk factors in LTRs. With projected continued increase in cardiac risk burden and the proportion of patients transplanted for NASH, it is critical for LT programs to develop and implement quality improvement efforts to optimize CV care in LTRs.
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Affiliation(s)
- Claire R Harrington
- Division of GI and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Paul Levy
- Division of GI and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth Cabrera
- Division of GI and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jing Gao
- Division of GI and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dyanna L Gregory
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Cynthia Padilla
- Division of GI and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gonzalo Crespo
- Hepatology and Liver Transplant Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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31
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Tsochatzis EA, Watt KD, VanWagner LB, Verna EC, Berzigotti A. Evaluation of recipients with significant comorbidity - Patients with cardiovascular disease. J Hepatol 2023; 78:1089-1104. [PMID: 37208096 PMCID: PMC11856630 DOI: 10.1016/j.jhep.2023.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
Liver transplant(ation) (LT) is the most effective treatment for patients with decompensated liver disease. The increasing prevalence of obesity and type 2 diabetes and the growing number of patients with non-alcoholic fatty liver disease being evaluated for LT, have resulted in a greater proportion of LT candidates presenting with a higher risk of cardiovascular disease. As cardiovascular disease is a major cause of morbidity and mortality after LT, a thorough cardiovascular evaluation pre-LT is crucial. In this review, we discuss the latest evidence on the cardiovascular evaluation of LT candidates and we focus on the most prevalent conditions, namely ischaemic heart disease, atrial fibrillation and other arrhythmias, valvular heart disease, and cardiomyopathies. LT candidates undergo an electrocardiogram, a resting transthoracic echocardiography and an assessment of their cardiopulmonary functional ability as part of their standardised pre-LT work-up. Further diagnostic work-up is undertaken based on the results of the baseline evaluation and may include a coronary computed tomography angiography in patients with cardiovascular risk factors. The evaluation of potential LT candidates for cardiovascular disease requires a multidisciplinary approach, with input from anaesthetists, cardiologists, hepatologists and transplant surgeons.
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Affiliation(s)
- Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Campus, London, UK; Sheila Sherlock Liver Unit, Royal Free Hospital, London, UK.
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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Koshy AN, Sampaio Rodrigues T, Gow PJ, Cailes B, VanWagner LB, Farouque O. Drug-eluting stent use with abbreviated dual antiplatelet therapy after percutaneous coronary intervention for liver transplantation evaluation. Liver Transpl 2023; 29:459-462. [PMID: 36749286 DOI: 10.1097/lvt.0000000000000090] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/11/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Thalys Sampaio Rodrigues
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Paul J Gow
- The University of Melbourne, Parkville, Victoria, Australia
- Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Lisa B VanWagner
- Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Centre, Dallas, Texas, USA
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
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33
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Rodas FV, Shankar N. NAFLD: A pretransplant and post-transplant conundrum. Clin Liver Dis (Hoboken) 2023; 21:93-98. [PMID: 37936953 PMCID: PMC10627585 DOI: 10.1097/cld.0000000000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/12/2023] [Indexed: 11/09/2023] Open
Abstract
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Affiliation(s)
- Fabian V. Rodas
- University of Texas Health Science Center San Antonio—UTHSCSA, The Texas Liver Institute, San Antonio, Texas, USA
| | - Nagasri Shankar
- University of Texas Health Science Center San Antonio—UTHSCSA, San Antonio, Texas, USA
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34
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High Coronary Artery Calcium Score Is Associated With Increased Major Adverse Cardiac Events After Liver Transplantation. Transplant Direct 2023; 9:e1426. [PMID: 36700067 PMCID: PMC9820787 DOI: 10.1097/txd.0000000000001426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 01/27/2023] Open
Abstract
Liver transplantation (LT) candidates frequently have multiple cardiovascular risk factors, and cardiovascular disease is a major cause of morbidity and mortality after LT. Coronary artery calcium (CAC) scores are a noninvasive assessment of coronary artery disease using computed tomography. This study examines CAC scores and cardiac risk factors and their association with outcomes after LT. Methods Patients who underwent LT between January 2010 and June 2019 with a pretransplant CAC score were included in this study. Patients were divided by CAC score into 4 groups (CAC score 0, CAC score 1-100, CAC score 101-400, CAC score >400). Major adverse cardiovascular events (MACEs) were defined as myocardial infarction, stroke, revascularization, heart failure, atrial fibrillation, and cardiovascular death. Associations between CAC score and MACE or all-cause mortality within the 5-y post-LT follow-up period were analyzed using Cox regression. Statistical significance was defined as P < 0.05. Results During the study period, 773 adult patients underwent their first LT, and 227 patients met our study criteria. The median follow-up time was 3.4 (interquartile range 1.9, 5.3) y. After 5 y, death occurred in 47 patients (20.7%) and MACE in 47 patients (20.7%). In multivariable analysis, there was no difference in death between CAC score groups. There was significantly higher risk of MACE in the CAC score >400 group, with a hazard ratio 2.58 (95% confidence interval 1.05, 6.29). Conclusions CAC score was not associated with all-cause mortality. Patients with CAC score >400 had an increase in MACEs within the 5-y follow-up period compared with patients with a CAC score = 0. Further research with larger cohorts is needed to examine cardiac risk stratification in this vulnerable patient population.
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35
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Doycheva I, Izzy M, Watt KD. Cardiovascular assessment before liver transplantation. CARDIO-HEPATOLOGY 2023:309-326. [DOI: 10.1016/b978-0-12-817394-7.00005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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36
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[Liver transplantation in aged patients]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:28-35. [PMID: 36633652 DOI: 10.1007/s00104-022-01776-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Due to the demographic changes and the increasing incidence of chronic, especially nutritively toxic liver diseases, the number of patients over 65 years of age with indications for liver transplantation is rising considerably. Patient age alone is not a contraindication for organ transplantation; however, in order to ensure the postoperative outcome, a structured interdisciplinary assessment is necessary, especially in older potential organ recipients. With knowledge of comorbidities, individualized prehabilitation enables the perioperative risk to be minimized. The postoperative morbidity in aged patients appears to be comparable to that of younger patients, especially after careful evaluation. Overall, there is a clear survival advantage compared with the best conservative treatment for liver disease. In addition to the perioperative procedure, differences in follow-up care and long-term outcome should also be considered. In this context, predominantly the pharmacological peculiarities, such as polypharmacy and the mutual influence of immunosuppression and comorbidities, have to be taken into account. In addition to old organ recipients, livers from old donors (so-called marginal organs) increasingly play a crucial role in transplantation medicine due to the organ shortage. These are more susceptible to ischemia reperfusion injury and thus put the recipient at a higher risk for delayed or lack of organ function recovery. New ethical issues are raised by the increasing age of donors and recipients, complicating decision making about organ acceptance or rejection for the transplantation physician.
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Yao S, Iwashita A, Yagi S, Watanabe H, Nishio T, Koyama Y, Nagai K, Kamo N, Taura K, Hatano E. Acute coronary syndrome after liver transplantation in a young primary biliary cholangitis recipient with dyslipidemia: a case report. Surg Case Rep 2022; 8:113. [PMID: 35713737 PMCID: PMC9206063 DOI: 10.1186/s40792-022-01470-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Primary biliary cholangitis (PBC) is a chronic, progressive liver disease associated with dyslipidemia. There is a consensus that PBC does not accelerate coronary artery disease despite high cholesterol levels, so the screening test for the coronary artery is not routinely performed before liver transplantation (LT). To date, no report has described the potential risk of PBC-related dyslipidemia for developing acute coronary syndrome (ACS) after LT.
Case presentation
A 40-year-old Asian female with a known history of PBC underwent ABO-incompatible living-donor LT, with her husband as the donor. Although she had high cholesterol and triglyceride levels that were refractory to medications, she passed all routine preoperative examinations, including cardiopulmonary function tests and infection screenings. One week after LT, she developed ACS with 90% stenosis of both the left anterior descending artery and left circumflex artery. Emergent stent implantation was successfully performed followed by dual antiplatelet therapy. The long history of PBC and associated severe dyslipidemia for 10 years would have accelerated the atherosclerosis, causing latent stenosis in the coronary artery. Inapparent stenosis might have become apparent due to unstable hemodynamics during the acute phase after LT.
Conclusions
PBC-related dyslipidemia potentially brings a risk for developing ACS after LT. This experience suggests that the preoperative evaluation of the coronary artery should be considered for high-risk patients, especially those who have drug-resistant dyslipidemia.
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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Rivas E, Sasaki K, Liang C, Wang J, Quintini C, Maheshwari K, Turan A, Fares M, Cywinski JB. New-Onset Atrial Fibrillation in Patients Undergoing Liver Transplantation: Retrospective Analysis of Risk Factors and Outcomes. J Cardiothorac Vasc Anesth 2022; 36:4100-4107. [PMID: 35999113 DOI: 10.1053/j.jvca.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to identify predictors of new-onset postoperative atrial fibrillation (POAF) during the initial 90 days following liver transplantation, and to assess the association between POAF in-hospital and 1-year mortality. DESIGN A retrospective cohort study. SETTING At a university hospital between 2005 and 2017. PATIENTS Adults without a history of preoperative atrial fibrillation who underwent orthotopicliver transplantation. MEASUREMENT AND MAIN RESULTS The authors assessed the univariate association between new-onset of POAF in the postoperative period and each potential factor through a logistic regression model. Moreover, they explored predictors for POAF through stepwise selection. Finally, the authors assessed the relationship between POAF and in-hospital and 1-year mortality using logistic regression models, and whether the duration of atrial fibrillation was associated with in-hospital and 1-year mortality. Among 857 patients, 89 (10.4%) developed POAF. Using only preoperative variables, pulmonary hypertension, age, Model for End-Stage Liver Disease (MELD) score, and White race were identified as the most important predictors. Model discrimination was 0.75 (95% CI: 0.69-0.80), and incorporating intraoperative variables was 0.77 (95% CI: 0.72-0.82). In-hospital mortality was observed in 7.2% (6/83) of patients with new-onset of POAF, and in 2.8% (22/768) without, with confounder-adjusted odds ratio (OR) 1.00 (97.5% CI: 0.29,3.45; p = 0.996). One-year mortality was 22.4% (20/89) in patients who developed POAF and 8.3% (64/768) in patients who did not, confounder-adjusted OR 2.64 (97.5% CI: 1.35-5.16; p = 0.001). The duration of POAF did not affect long-term postoperative mortality. CONCLUSION Preoperative, mostly unmodifiable comorbidities are important risk factors for new-onset POAF after liver transplantation. The POAF was not associated with in-hospital mortality, but with increased 1-year mortality. Once developed, the duration of POAF did not affect long-term mortality after a liver transplant.
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Affiliation(s)
- Eva Rivas
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Kazunari Sasaki
- Department of Liver Transplant, Cleveland Clinic, Cleveland, OH
| | - Chen Liang
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Jiayi Wang
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH
| | | | - Kamal Maheshwari
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Alparslan Turan
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Maan Fares
- Department of Cardiology, Cleveland Clinic, Cleveland, OH
| | - Jacek B Cywinski
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH.
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40
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Lim WH, Chew NW, Quek J, Ng CH, Tan DJH, Xiao J, Nah B, Lee GH, Huang DQ, Tan EXX, Muthiah MD. Echocardiographic assessment of cardiovascular function and clinical outcomes in liver transplant recipients. Clin Transplant 2022; 36:e14793. [PMID: 35962725 DOI: 10.1111/ctr.14793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/27/2022] [Accepted: 08/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Cardiovascular disease contributes to a high rate of morbidity and mortality after liver transplantation (LT). However, the progression of cardiac function and cardiac remodeling in LT recipients remains poorly understood. This study sought to evaluate the progression of cardiac function and structure in LT recipients and identify independent predictors of prognosis using echocardiography. METHODS From 2009 to 2019, 178 adult LT recipients at a tertiary academic transplant center were retrospectively studied. Transthoracic echocardiograms 1-year pre- and post-LT were assessed. Primary outcomes were progression of systolic and diastolic function. Secondary outcomes included left ventricular remodeling, all-cause mortality, and heart failure readmission post-LT. Subgroup analyzes were performed for etiology of native liver disease. A multivariable model was constructed to examine independent predictors of outcomes. RESULTS Systolic function significantly worsened, with reduction in stroke volume (45-37 ml/m2 , p < .001), left ventricular ejection fraction (LVEF) (65%-62%, p < .001) and cardiac index (3.00-2.60 L/min/m2 , p < .001). Conversely, there were significant improvements in diastolic indices, including tricuspid regurgitation Vmax (228-215 cm/s, p = .017), left atrial volume index (LAVI) (32-26 ml/m2 , p < .001) and right ventricular systolic pressure (RVSP) (31-28 mmHg, p = .001). Additionally, patients had increased relative wall thickness (RWT) (p < .001) and decreased left ventricular end-diastolic dimension/body surface area (p < .001) post-LT. The independent predictors for all-cause mortality and heart failure were increased pre-LT mitral annular early diastolic velocity (HR 1.11, CI 1.02-1.22, p = .018), LAVI (HR 1.06, CI 1.02-1.11, p = .007) and decreased LVEF (HR .89, CI .82-.97, p = .006). The effect of non-alcoholic steatohepatitis on cardiovascular outcomes post-LT was largely comparable to that of Hepatitis B. CONCLUSION This study showed reduced systolic and improved diastolic function in LT recipients and highlighted the utility of pre-LT echocardiogram in the prognostication and risk stratification of LT candidates.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Ws Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Jingxuan Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Nah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Guan Huei Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
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41
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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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42
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Kozlik A, Wiseman K, Upadhyaya VD, Sharma A, Chatterjee S. Preoperative Coronary Intervention Before Orthotopic Liver Transplantation (from a Review of Literature). Am J Cardiol 2022; 185:94-99. [DOI: 10.1016/j.amjcard.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022]
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43
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Izzy M, DuBrock HM. CAQ Corner: Cardiovascular and pulmonary evaluation of liver transplantation candidates: What you need to know for the board exam. Liver Transpl 2022; 28:1529-1538. [PMID: 35470532 DOI: 10.1002/lt.26495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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44
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Bhave NM, Sharma P, Eagle KA. Hearts of Steel. JACC Case Rep 2022; 4:682-684. [PMID: 35677798 PMCID: PMC9168955 DOI: 10.1016/j.jaccas.2022.04.008] [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: 12/03/2022]
Affiliation(s)
- Nicole M. Bhave
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan and Michigan Medicine, Ann Arbor, Michigan, USA
- Address for correspondence: Dr Nicole M. Bhave, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan and Michigan Medicine, 2362 Cardiovascular Center, 1500 East Medical Center Drive, SPC 5853, Ann Arbor, Michigan 48109-5853, USA.
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan and Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kim A. Eagle
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan and Michigan Medicine, Ann Arbor, Michigan, USA
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45
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Rhee JW, Zhang S, Gallo A, Ahmed A, Kawana M. Severe Cardiovascular Complications Following Liver Transplantation in Patients With Iron Overload. JACC Case Rep 2022; 4:677-681. [PMID: 35677787 PMCID: PMC9168775 DOI: 10.1016/j.jaccas.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022]
Abstract
We report 4 cases of our institutional experience with liver transplantation that illustrate the high risk of heart failure and cardiogenic shock in the setting of cardiac iron overload. We then discuss a pragmatic approach to assess the cardiovascular risk in liver transplantation candidates with cardiac iron overload. (Level of Difficulty: Advanced.)
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46
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Nayagam JS, Norton BC, Belete S, Rosinhas J, Ramos K, Cramp ME, O'Kane R, Cash WJ, Milan Z, Nicholson C, Menon K, Prachalias A, Srinivasan P, Auzinger G, Byrne J, MacCarthy PA, Melikian N, Agarwal K, Aluvihare VR, Joshi D, Heneghan MA. Invasive coronary angiography as a tool in cardiac evaluation for liver transplant candidates. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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47
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Han S, Park J, Hong SH, Park CS, Choi J, Chae MS. Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view. Anesth Pain Med (Seoul) 2022; 17:132-144. [PMID: 35538654 PMCID: PMC9091670 DOI: 10.17085/apm.22132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/19/2022] Open
Abstract
Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.
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Affiliation(s)
- Sangbin Han
- Department of Emergency Medicine, Cheongyang Health Center County Hospital, Cheongyang, Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jongho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Corresponding author Min Suk Chae, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: 82-2-2258-6150 Fax: 82-2-537-1951 E-mail:
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48
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Mohammadi F, Ramachandran J, Woodman R, Muller K, John L, Chen J, Wigg A. Impact of cardiac dysfunction on morbidity and mortality in liver transplant candidates. Clin Transplant 2022; 36:e14682. [PMID: 35441375 DOI: 10.1111/ctr.14682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/30/2022] [Accepted: 04/09/2022] [Indexed: 11/29/2022]
Abstract
The prognostic role of cardiac dysfunction in cirrhotic patients is increasingly recognised. We studied its impact on morbidity and mortality before and after liver transplantation (LT) including development of post-transplant cardiovascular disease (CVD). In this retrospective study, cirrhotic patients who underwent LT assessment from January 2010 to December 2020 were reviewed. Demographics, cardiac investigations and clinical course were analysed to identify prevalence of cardiac dysfunction and its role in LT outcomes. Survival analysis was performed using Cox proportional hazard regression modelling, with LT as a time-varying covariate and as an interaction variable with cardiac dysfunction. 308 patients (70% male) were studied. The median (interquartile range) age at LT assessment was 56 (12) years. Cardiac dysfunction was found in 178 (58%) patients (diastolic, 169; systolic, 26; both, 17) and was significantly associated with hepatorenal syndrome/acute kidney injury and peri- and post-transplant morbidity (adjusted odds ratio [aOR] 1.94, 95%CI 1.06-3.52, p < 0.001; aOR 2.01, 95%CI 1.06-3.82, p = 0.033; aOR 1.9, 95%CI 1.01-3.65, p = 0.023, respectively). Cardiac dysfunction was not associated with mortality before (adjusted hazard ratio [aHR] 1.01, 95% CI 0.99-1.01) or after LT (aHR 0.74, 95% CI 0.4-1.05. Post-transplant CVD (61% cardiac failure) occurred in 36 patients and there was no significant association with cardiac dysfunction (p = 0.11). Cardiac dysfunction was common in LT candidates and was significantly associated with morbidity before and after LT. Studies on the role of advanced echocardiographic parameters to improve diagnosis of cardiac dysfunction and optimise LT outcomes are needed. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fadak Mohammadi
- Hepatology Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, South Australia, Australia.,College of Medicine and Public Health, Flinders University, South Australia, Australia.,South Australian Liver Transplant Unit, Flinders Medical Centre, South Australia, Australia
| | - Jeyamani Ramachandran
- Hepatology Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, South Australia, Australia.,College of Medicine and Public Health, Flinders University, South Australia, Australia.,South Australian Liver Transplant Unit, Flinders Medical Centre, South Australia, Australia
| | - Richard Woodman
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Kate Muller
- Hepatology Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, South Australia, Australia.,College of Medicine and Public Health, Flinders University, South Australia, Australia.,South Australian Liver Transplant Unit, Flinders Medical Centre, South Australia, Australia
| | - Libby John
- South Australian Liver Transplant Unit, Flinders Medical Centre, South Australia, Australia
| | - John Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, South Australia, Australia
| | - Alan Wigg
- Hepatology Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, South Australia, Australia.,College of Medicine and Public Health, Flinders University, South Australia, Australia.,South Australian Liver Transplant Unit, Flinders Medical Centre, South Australia, Australia
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49
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McCarthy KJ, Motta-Calderon D, Estrada-Roman A, Cajiao KM, Curry MP, Bonder A, Anagnostopoulos AM, Gavin M. Introduction of a standardized protocol for cardiac risk assessment in candidates for liver transplant - A retrospective cohort analysis. Ann Hepatol 2022; 27:100582. [PMID: 34808392 DOI: 10.1016/j.aohep.2021.100582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/27/2021] [Accepted: 10/11/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recommendations on non-invasive imaging to assess pre-operative cardiac risk among liver transplant candidates vary amongst societal guidelines and individual institutional practices. In 2018, a standardized pre-transplant coronary evaluation protocol was established at Beth Israel Deaconess Medical Center, Boston MA, to ensure appropriate and consistent pre-operative testing was performed. METHODS All patients who underwent liver transplant evaluation between January 1st, 2016 and December 31st, 2019, were retrospectively analyzed and divided into three cohorts; before the introduction of the protocol (prior to 2018), initial protocol favoring invasive coronary angiography (ICA) (2018), and amended protocol favoring coronary computed tomography angiography (CCTA) (post-2018). We described clinical characteristics, candidacy for transplant, and cardiovascular complications during follow-up. As an unadjusted exploratory analysis, the Cochran-Armitage Exact Trend Test was used to examine univariate differences across time. RESULTS A total of 462 patients underwent liver transplant evaluation during the study period. Among these, 218 (47.2%) patients underwent stress test, 50 (10.8%) underwent CCTA, and 68 (14.8%) underwent ICA. Across the three time periods, there was an increase in the proportion of CCTAs performed (3%, 6.3%, and 26.3% respectively; p <0.001) and proportion of patients diagnosed with obstructive CAD using CCTA (0%, 30%, and 51.4% respectively; p = 0.04). There was no significant difference in post-transplant cardiac complications among patients evaluated before 2018, during 2018, and after 2018 (5.9% vs. 5.6 vs. 6.0%; p=1.0). CONCLUSION Our findings suggest it is reasonable to shift practice to a less invasive approach utilizing CCTA or nuclear stress testing when assessing liver transplant candidates at increased cardiovascular risk.
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Affiliation(s)
- Killian J McCarthy
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Daniel Motta-Calderon
- Division of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Karen M Cajiao
- Division of Medicine, St. Mary's Hospital, Waterbury, CT, United States
| | - Michael P Curry
- Division of Hepatology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Alan Bonder
- Division of Hepatology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | | | - Michael Gavin
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA, United States.
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50
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Xiao J, Yong JN, Ng CH, Syn N, Lim WH, Tan DJH, Tan EY, Huang D, Wong RC, Chew NWS, Tan EXX, Noureddin M, Siddiqui MS, Muthiah MD. A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients. Liver Transpl 2022; 28:689-699. [PMID: 34626045 DOI: 10.1002/lt.26331] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.
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Affiliation(s)
- Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - En Ying Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Raymond C Wong
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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