Corrected QT interval on the electrocardiogram after liver transplantation: Surrogate marker of poor clinical outcomes?

Lee, Seung Hwa; Park, Myung-Soo; Park, Kyoung‐Min; Gwag, Hye-bin; Park, Jungchan; Kim, Jeayoun; Choi, Gyu‐Seong; Lee, Suk-Koo; Kim, Gaab Soo

doi:10.1371/journal.pone.0206463

Cited by 8 publications

(6 citation statements)

References 25 publications

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“…( 66 ) However, posttransplant long QTc has been linked with increased risk of death. ( 67 ) As patients with pre‐existing ventricular arrhythmias are not considered for LT, there are little data regarding its impact on posttransplant outcomes. In 2020, Koshy et al developed a point‐based cardiac arrest risk index for prediction of periprocedural (30‐day) cardiac arrest and ventricular arrhythmias.…”

Section: Arrhythmiamentioning

confidence: 99%

Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions

Barman

VanWagner

2021

Hepatology

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In the changing landscape of liver transplantation (LT), we are now evaluating older and sicker patients with more cardiovascular comorbidities, and the spectrum of cardiovascular disease is uniquely physiologically impacted by end‐stage liver disease. Cardiac complications are now the leading cause of morbidity and mortality in LT recipients, and the pretransplant risk is exacerbated immediately during the transplant operation and continues long term under the umbrella of immunosuppression. Accurate risk estimation of cardiac complications before LT is paramount to guide allocation of limited health care resources and to improve both short‐term and long‐term clinical outcomes for patients. Current screening and diagnostic testing are limited in their capacity to accurately identify early coronary disease and myocardial dysfunction in persons with end‐stage liver disease physiology. Furthermore, a number of testing modalities have not been evaluated in patients with end‐stage liver disease. As a result, there is wide variation in cardiac risk assessment practices across transplant centers. In this review, we propose a definition for defining cardiac events in LT, evaluate the current evidence for surgery‐related, short‐term and long‐term cardiac risk assessment in LT candidates, propose an evidence‐based testing algorithm, and highlight specific gaps in knowledge and current controversies, identifying areas for future research.

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Section: Arrhythmiamentioning

confidence: 99%

Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions

Barman

VanWagner

2021

Hepatology

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“…Evidence suggests that it not only predicts sudden cardiac death but is also involved in its pathogenesis 18 . Studies in patients undergoing LT have evaluated the association of QT interval prolongation and cardiovascular events with mixed results 14,15,19‐21 . However, none have evaluated whether QT prolongation is associated with CA/VAs after LT 22,23 .…”

Section: Introductionmentioning

confidence: 99%

Effect of QT interval prolongation on cardiac arrest following liver transplantation and derivation of a risk index

Koshy

Farouque

et al. 2021

American Journal of Transplantation

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Liver transplantation (LT) has a 4‐fold higher risk of periprocedural cardiac arrest and ventricular arrhythmias (CA/VAs) compared with other noncardiac surgeries. Prolongation of the corrected QT interval (QTc) is common in patients with liver cirrhosis. Whether it is associated with an increased risk of CA/VAs following LT is unclear. Rates of 30‐day CA/VAs post‐LT were assessed in consecutive adults undergoing LT between 2010 and 2017. Pretransplant QTc was measured by a cardiologist blinded to clinical outcomes. Among 408 patients included, CA/VAs occurred in 26 patients (6.4%). QTc was significantly longer in CA/VA patients (475 ± 34 vs 450 ± 34 ms, P < .001). Optimal QTc cut‐off for prediction of CA/VAs was ≥480 ms. After adjustment, QTc ≥480 ms remained the strongest predictor for the occurrence of CA/VAs (odds ratio [OR] 5.2, 95% confidence interval [CI] 2.2‐12.6). A point‐based cardiac arrest risk index (CARI) was derived with the bootstrap method for yielding optimism‐corrected coefficients (2 points: QTc ≥480, 1 point: Model for End‐Stage Liver Disease [MELD] ≥30, 1 point: age ≥65, and 1 point: male). CARI score ≥3 demonstrated moderate discrimination (c‐statistic 0.79, optimism‐corrected c‐statistic 0.77) with appropriate calibration. QTc ≥480 ms was associated with a 5‐fold increase in the risk of CA/VAs. The CARI score may identify patients at higher risk of these events. Whether heightened perioperative cardiac surveillance, avoidance of QT prolonging medications, or beta blockers could mitigate the risk of CA/VAs in this population merits further study.

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“…Similar results were presented before in smaller populations. 19 , 54 Lee et al 90 reported no significant difference in outcome when using an ECG prior to the transplant, but a 78% higher mortality if QTc prolongation was present 1 month after liver transplant.…”

Section: Risk Of Lqts In Cirrhosismentioning

confidence: 99%

Prolonged QT Interval in Cirrhosis: Twisting Time?

et al. 2022

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Approximately 30% to 70% of patients with cirrhosis have QT interval prolongation. In patients without cirrhosis, QT prolongation is associated with an increased risk of ventricular arrhythmias, such as torsade de pointes (TdP). In cirrhotic patients, there is likely a significant association between the corrected QT (QTc) interval and the severity of liver disease, and possibly with increased mortality. We present a stepwise overview of the pathophysiology and management of acquired long QT syndrome in cirrhosis. The QT interval is mainly determined by ventricular repolarization. To compare the QT interval in time it should be corrected for heart rate (QTc), preferably by the Fridericia method. A QTc interval >450 ms in males and >470 ms in females is considered prolonged. The pathophysiological mechanism remains incompletely understood, but may include metabolic, autonomic or hormonal imbalances, cirrhotic heart failure and/or genetic predisposition. Additional external risk factors for QTc prolongation include medication (I Kr blockade and altered cytochrome P450 activity), bradycardia, electrolyte abnormalities, underlying cardiomyopathy and acute illness. In patients with cirrhosis, multiple hits and cardiac-hepatic interactions are often required to sufficiently erode the repolarization reserve before long QT syndrome and TdP can occur. While some risk factors are unavoidable, overall risk can be mitigated by electrocardiogram monitoring and avoiding drug interactions and electrolyte and acidbase disturbances. In cirrhotic patients with prolonged QTc interval, a joint effort by cardiologists and hepatologists may be useful and significantly improve the clinical course and outcome.

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Corrected QT interval on the electrocardiogram after liver transplantation: Surrogate marker of poor clinical outcomes?

Cited by 8 publications

References 25 publications

Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions

Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions

Effect of QT interval prolongation on cardiac arrest following liver transplantation and derivation of a risk index

Prolonged QT Interval in Cirrhosis: Twisting Time?

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