State-of-the-Art Paper
Cardiovascular Risk Assessment of the Liver Transplant Candidate

https://doi.org/10.1016/j.jacc.2011.03.026Get rights and content
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Liver transplantation (LT) candidates today are increasingly older, have greater medical acuity, and have more cardiovascular comorbidities than ever before. Steadily rising model for end-stage liver disease (MELD) scores at the time of transplant, resulting from high organ demand, reflect the escalating risk profiles of LT candidates. In addition to advanced age and the presence of comorbidities, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Patients with cirrhosis requiring LT usually demonstrate increased cardiac output and a compromised ventricular response to stress, a condition termed cirrhotic cardiomyopathy. These cardiac disturbances are likely mediated by decreased beta-agonist transduction, increased circulating inflammatory mediators with cardiodepressant properties, and repolarization changes. Low systemic vascular resistance and bradycardia are also commonly seen in cirrhosis and can be aggravated by beta-blocker use. These physiologic changes all contribute to the potential for cardiovascular complications, particularly with the altered hemodynamic stresses that LT patients face in the immediate post-operative period. Post-transplant reperfusion may result in cardiac death due to a multitude of causes, including arrhythmia, acute heart failure, and myocardial infarction. Recognizing the hemodynamic challenges encountered by LT patients in the perioperative period and how these responses can be exacerbated by underlying cardiac pathology is critical in developing recommendations for the pre-operative risk assessment and management of these patients. The following provides a review of the cardiovascular challenges in LT candidates, as well as evidence-based recommendations for their evaluation and management.

Key Words

coronary artery disease
end-stage liver disease
liver transplant

Abbreviations and Acronyms

CAD
coronary artery disease
CT
computed tomography
DM
diabetes mellitus
DSE
dobutamine stress echocardiography
ESLD
end-stage liver disease
HPS
hepatopulmonary syndrome
LT
liver transplantation
LVOTO
left ventricular outflow tract obstruction
MELD
model for end-stage liver disease
mPAP
mean pulmonary arterial pressure
NPV
negative predictive value
PFO
patent foramen ovale
POPH
portopulmonary hypertension
QTc
corrected QT interval
SPECT
single-positron emission computed tomography
TTE
transthoracic echocardiography

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Dr. Gheorghiade is a consultant for Abbott Laboratories, Astellas, AstraZeneca, Bayer Schering Pharma AG, CorThera Inc., Cytokinetics Inc., DebioPharm S.A., Errekappa Terapeuitici, GlaxoSmithKline, Johnson & Johnson, Medtronic, Merck, Novartis Pharma AG, Otsuka Pharmaceuticals, Pericor Therapeutics, Protein Design Laboratories, Sanofi-Aventis, Sigma Tau, and Solvay Pharmaceuticals. All other authors have reported that they have no relationships to disclose.