Cardiac diseases among liver transplant candidates

Abstract

Improvements in early survival after liver transplant (LT) have allowed for the selection of LT candidates with multiple comorbidities. Cardiovascular disease is a major contributor to post-LT complications. We performed a literature search to identify the causes of cardiac disease in the LT population and to describe techniques for diagnosis and perioperative management. As no definite guidelines for preoperative assessment (except for pulmonary heart disease) are currently available, we recommend an algorithm for preoperative cardiac work-up.

Preoperative cardiac assessment in liver transplant candidates

“…This is at variance with from the AASLD guidelines, which recommend only basal TTE [5]. In line with the most recent reviews dealing with preoperative cardiac evaluation for non-cardiac surgery [23,24], we and others [1,20,21,25,26] strongly support, together with the above cited basic instrumental tests, a chest radiological imaging, clinical history and physical examination and a preliminary "subjective" functional assessment of the cardiac reserve using the definition of the metabolic equivalents [METs]. The latter is now better defined by the DASI score questionnaire, more objective, very well correlated in the high risk general surgical population to peak oxygen consumption (VO2 peak) and complications [27] , even if not yet specifically validated in the LT candidates [28].…”

“…In case of CCM, the recommendations for prolonged QT (> 450 msec in males or > 470 msec in females) recently endorsed by ATS are to treat reversible causes and to avoid medications able to prolong QT (GRADE recommendation 1C) [9] 2.2 Biomarkers -Biomarkers may have an interesting role as non-invasive diagnostic and prognostic tools in the preoperative period [31,33,34]. Some Authors suggest the preoperative use of cardiac Troponin I (cTn I) level, now used for the general surgical population, as a marker of subclinical myocardial damage [25,35].…”

“…In the most recent nested cohort analysis of that study the Authors were able to define a cut-off of 34 as a threshold to identify surgical patients at increased risk for myocardial injury, myocardial infarction, and moderate-to-severe complications [28]. The role of METs (recommended by the AHA guidelines [23] and included in some stepwise algorithms [1,21,25,26], or nowadays of the DASI score, deserves a specific validation in preoperative LT assessment.…”

“…In the last twenty years the population of LT candidates has changed: much wider indications (alcoholrelated cirrhosis, NAFLD / NASH) and candidates sometimes in their seventies have consistently increased the risk of CAD and its potential complications in recipients [1,5,6,9,16,18,25]. Consensus recommendation [9] states that non-revascularized severe multivessel CAD constitutes an absolute contraindication to LT, while "moderate" obstruction not involving left main or proximal left anterior descending (LAD) coronary arteries, even if non revascularized, is considered a relative contraindication [9].…”

Aspectos fisiopatológicos y diagnósticos de la miocardiopatía cirrótica

“…En esta condición, los cambios de la arquitectura hepática restringen el flujo sanguíneo hacia la aurícula derecha y el volumen se almacena en la circulación esplácnica, lo que activa mecanismos fisiopatológicos que progresivamente inducen vasodilatación. No se han definido por completo estos mecanismos, sin embargo, se reconoce un aumento de sustancias vasodilatadoras como el óxido nítrico (NO), el monóxido de carbono (CO), la adrenomedulina, el factor de necrosis tumoral alfa (TNF-α) y los endocannabinoides, con una reducción simultánea de la sensibilidad a sustancias vasoconstrictoras 10,[14][15][16][17][18] .…”