Acute Heart Failure Post Liver Transplantation: A Systematic Literature Review

Abstract

Purpose Acute severe heart failure (HF) developing shortly, within hours or days, after orthotopic liver transplantation (OLT) is a known but poorly understood phenomenon. The pattern of echocardiographic changes with profound drop in left ventricular ejection fraction (LVEF) and regional wall motion abnormalities typically matches Takotsubo cardiomyopathy. Our purpose is to conduct a literature review and analysis of all the published cases that had acute severe HF after OLT. Methods We found 20 published peer reviewed case studies that described cases of HF after OLT with individual patient data available. We excluded cases of patients that had any transplant other than liver. We compiled and analyzed all the available data from each of these cases using an Excel spreadsheet. Results Our final sample had 63 patients, 56% of which were males, who developed acute HF post OLT with a mean age of 55±10, median of 57, and ranging 26-73.The average Model for End-Stage Liver Disease score was 26 ±8. In 31 patients, ischemic evaluations were performed with either a nuclear stress, dobutamine stress, or angiography and almost all (97%) of them had no evidence of ischemia. Of the 49 patients with Biomarker data, 45 (92%) had a rise in cardiac markers (troponin or CKMB). Of the 17 patients with ECG data, 10 (59%) had abnormalities at the time of HF and 8 out of 9 (89%) had a prolonged QTc. On average, acute HF developed in 1.9 ± 2.7 days after OLT (median 1 day). The mean Left Ventricular Ejection Fraction (LVEF) prior to surgery was 62.2% ±7.3 and dropping to a mean of 23.2% ± 8.2 after surgery. Of the 39 cases with known outcomes, 9 (23%) had died and five of them for cardiac reasons. 28 (72%) had full EF recovery, 5 (13%) had incomplete EF recovery, and 6 (15%) had no EF recovery. The average Recovered LVEF was 51.4% ± 13.1. Of 54 patients with reported echocardiographic findings, 52 (96%) had findings that were consistent with Takotsubo Cardiomyopathy. Conclusion Acute HF post liver transplant is diagnosed within hours to days after OLT and results in high mortality (23%). A rapid drop in LVEF with frequent recovery (85%), elevated cardiac enzymes, negative ischemic evaluation, and ECG changes suggest Takotsubo-like syndrome. The timing of changes suggests that most cases of takotsubo post liver transplant get triggered intraoperatively. Patients should be aggressively supported as they have a good potential for recovery.