Liver Transplantation as a Challenge for the Anesthesiologist: Preoperative Cardiac Assessment to Orient the Perioperative Period

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].…”

“…However, consensus on a standardized pre LT cardiovascular evaluation and risk stratification, even if long and eagerly awaited, is still lacking [1,5,7,9,10,18,20]. Cardiac assessment is then characterized by a large variation in guidelines, with different clinical pathways often "transplant center oriented" and difficult to be generalized, even if the relevant "pillars" sustaining its rationale are common to the various stepwise paradigms [1,9,10,[20][21][22]. As underlined by Sandal et al [10] while in case of symptomatic disease the pathways are quite well defined, risk assessment in the asymptomatic candidate is variable if not sometimes controversial (age of the candidate to perform cardiac stress test or the indication to coronary artery angiography, CA).…”

“…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.…”