Copyright
©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
Diagnostic accuracy and cost-effectiveness of the CAR-OLT score in predicting cardiac risk for liver transplantation
Marco Biolato, Luca Miele, Alfonso W Avolio, Giuseppe Marrone, Antonio Liguori, Francesco Galati, Anna Petti, Lidia Tomasello, Daniela Pedicino, Antonella Lombardo, Alessia D'Aiello, Maurizio Pompili, Salvatore Agnes, Antonio Gasbarrini, Antonio Grieco
Marco Biolato, Luca Miele, Giuseppe Marrone, Antonio Liguori, Maurizio Pompili, Antonio Gasbarrini, 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
Marco Biolato, Luca Miele, Alfonso W Avolio, Giuseppe Marrone, Antonio Liguori, Francesco Galati, Anna Petti, Lidia Tomasello, Maurizio Pompili, Salvatore Agnes, Antonio Gasbarrini, Antonio Grieco, Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Lazio, Italy
Alfonso W Avolio, Salvatore Agnes, General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome 00168, Lazio, Italy
Daniela Pedicino, Antonella Lombardo, 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
Author contributions: Biolato M, Miele L, and Avolio AW wrote the paper; Marrone G, Galati F, Petti A, and Tomasello L collected the data; Liguori A performed statistical analysis, Pedicino D, Lombardo A, D’Aiello A, Pompili M, Agnes S, Gasbarrini A, and Grieco A reviewed the manuscript for important intellectual content. All authors read and approved the final version.
Institutional review board statement: The study was approved by the ethics committee of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Lazio, Italy (resolution 4301, dated 8/7/2021).
Informed consent statement: Study participants provided informed written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Marco Biolato, MD, PhD, Staff Physician, 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), Largo A. Gemelli 8, Rome 00168, Lazio, Italy.
marco.biolato@policlinicogemelli.it
Received: July 16, 2024
Revised: December 13, 2024
Accepted: January 14, 2025
Published online: June 18, 2025
Processing time: 219 Days and 13.9 Hours
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.
Core Tip: The burden of cardiovascular risk factors and coronary artery disease among liver transplant (LT) candidates is increasing, but the optimal diagnostic cardiac work-up remains debated. The CAR-OLT score (available at www.carolt.us), based on twelve pre-transplant characteristics, predicts major adverse cardiovascular events one year after LT. In our population, a CAR-OLT score cut-off of ≤ 23 identifies low-risk patients who could directly proceed to LT listing without additional diagnostic tests. This approach could have avoided 87 stress tests and 13 coronary angiographies, saving an estimated €574.70 per patient for the Italian National Health System.
