Effect of liver transplantation on QT-interval prolongation and impact on mortality

Ko, Jefferson; Koshy, A.; Han, Haobo; Weinberg, Laurence; Gow, Paul J; Testro, Adam; Lim, H.; Farouque, Omar; Teh, A.

doi:10.1016/j.ijcard.2020.11.017

Cited by 13 publications

(19 citation statements)

References 27 publications

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“…QT interval prolongation is present in over 50% of patients with end‐stage liver disease 1,7,11 . The preponderance of this electrophysiological abnormality in patients with cirrhosis coupled with its inclusion in the 2005‐WCG criteria led to QT interval prolongation being considered synonymous with a diagnosis of CCM 5 .…”

Section: Discussionmentioning

confidence: 99%

“…QT interval prolongation on the other hand, increases the risk of posttransplant cardiac arrest with insufficient evidence linking it to cardiac decompensation, HRS, or poor survival 3,7,9,22‐24 . Moreover, unlike cardiac structural changes, there are concordant lines of evidence indicating a reversal of QT interval prolongation following liver transplantation 1,9,11,20,25 . These observations call into question the relationship between QT interval prolongation and the more established markers of cardiac structural and autonomic abnormalities in cirrhosis, including systolic and diastolic function, cardiac contractile reserve, and chronotropic incompetence 1,21 …”

Section: Discussionmentioning

confidence: 99%

“…CCM fundamentally refers to systolic dysfunction, altered diastolic indices, and an impaired contractile response to stress in patients with end‐stage liver disease and no known cardiac disease 1,5,6 . Historically, QT interval prolongation has been regarded as the electrophysiological hallmark of CCM and is present in 30%–60% of patients undergoing liver transplantation 1,7‐11 . The structural and electrophysiological features of CCM were collectively regarded as one entity according to the 2005 World Congress of Gastroenterology (2005‐WCG) definition, which lists QT interval prolongation as a supporting criterion for the diagnosis of CCM 5 .…”

Section: Introductionmentioning

confidence: 99%

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Relationship between QT interval prolongation and structural abnormalities in cirrhotic cardiomyopathy: A change in the current paradigm

Koshy

Gow

Testro

et al. 2021

American Journal of Transplantation

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It is postulated that cardiac structural abnormalities observed in cirrhotic cardiomyopathy (CCM) contribute to the electrophysiologic abnormality of QT interval (QTc) prolongation. We sought to evaluate whether QTc prolongation is associated with intrinsic abnormalities in cardiac structure and function that characterize CCM. Consecutive patients undergoing liver transplant work‐up between 2010 and 2018 were included. Measures of cardiac function on stress testing including cardiac reserve and chronotropic incompetence were collected prospectively and a corrected QTc ≥ 440 ms was considered prolonged. Overall, 439 patients were included and 65.1% had a prolonged QTc. There were no differences in markers of left ventricular and atrial remodeling, or resting systolic and diastolic function across QTc groups. The proportion of patients that met the criteria for a low cardiac reserve (39.2 vs 36.6%, p = .66) or chronotropic incompetence (18.1 vs 21.3%, p = .52) was not different in those with a QTc ≥ 440 vs <440 ms. Further, there was no association between QTc prolongation and CCM by either the 2005 World College of Gastroenterology or modified 2020 Cirrhotic Cardiomyopathy Consortium criteria. QT interval prolongation was not associated with structural or functional cardiac abnormalities that characterize CCM. These findings suggest that CCM and QT interval prolongation in cirrhosis may be two separate entities with distinct pathophysiological origins.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Relationship between QT interval prolongation and structural abnormalities in cirrhotic cardiomyopathy: A change in the current paradigm

Koshy

Gow

Testro

et al. 2021

American Journal of Transplantation

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“…5,19,54,86 Data after liver transplantation are again conflicting. Ko et al 89 reported changes in QTc intervals after transplant and reported QTc shortening in 73% of patients. They did not observe an association between the QTc interval after transplantation and mortality during follow-up.…”

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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“…QT interval prolongation: QT interval prolongation, considered a hallmark of cirrhotic cardiomyopathy, occurs in 30%-50% of patients with ESLD[ 110 - 112 ]. The mechanism for QT prolongation in ESLD can be multifactorial but only the Child-Pugh score has been found to be an independent predictor, with changes in plasma norepinephrine contributing to corrected QT (QTc) interval variability[ 110 , 113 ].…”

Section: Clinical Entitiesmentioning

confidence: 99%

Cardiac risk stratification of the liver transplant candidate: A comprehensive review

Nagraj¹,

Peppas²,

Guerrero³

et al. 2022

WJT

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Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.

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Effect of liver transplantation on QT-interval prolongation and impact on mortality

Cited by 13 publications

References 27 publications

Relationship between QT interval prolongation and structural abnormalities in cirrhotic cardiomyopathy: A change in the current paradigm

Relationship between QT interval prolongation and structural abnormalities in cirrhotic cardiomyopathy: A change in the current paradigm

Prolonged QT Interval in Cirrhosis: Twisting Time?

Cardiac risk stratification of the liver transplant candidate: A comprehensive review

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