Invited Commentary

Abstract

The morbidity and mortality associated with liver transplantation is significantly increased in patients with cardiac disease, and has especially been the case with coronary occlusive disease. As a result, the presence of untreated cardiac pathology has traditionally been considered a contraindication to liver transplantation. Unfortunately, previous studies have reported that in the presence of cirrhosis, attempts at correction of cardiovascular disease with cardiac surgery similarly carry a high risk of complications or death.Lima and colleagues [1Lima B. Nowicki E.R. Miller C.M. Hashimoto K. Smedira N.G. Gonzalez-Stawinski G.V. Outcomes of simultaneous liver transplantation and elective cardiac surgical procedures.Ann Thorac Surg. 2011; 92: 1580-1585Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] set out to explore whether the combination of elective cardiac surgical operations at the time of liver transplantation would result in improvement of outcomes. Although several previous reports of simultaneous cardiac operations and liver transplantation have been published, this represents the largest series to date.There are several promising findings in this study. When compared with the literature, the outcomes for morbidity and mortality compare favorably with those of patients with cirrhosis undergoing cardiac procedures without concomitant hepatic replacement. This seems to provide, as the authors state, the proof of concept that with the elimination of hepatic dysfunction as a postoperative complication, the surgical outcomes would be improved. Also, the addition of the cardiac surgical procedure did not appear to negatively affect acute or long-term hepatic allograft function. In addition, the presence of cardiac disease did not seem to alter the medium-term survival with respect to the occurrence of adverse cardiac events. As a result, it would seem plausible that many liver transplant programs might reconsider their stance and therapeutic strategies with regard to the presence of cardiac disease in potential recipients.Unfortunately, questions remain in this difficult patient population. As the authors freely admit, this was a highly selected patient group whose requisite variables for eligibility were stringent. Patients with reduced ventricular function and more advanced cardiac pathology were excluded and certainly might have altered the results. The reality is that contemporary liver transplant recipients are presenting with escalating risk profiles. In addition to valvular and coronary artery disease, patients with end-stage liver disease may have an associated cirrhotic cardiomyopathy and portopulmonary hypertension. Neither is a surgical entity, and both may respond only partially to medical management. When severe, they can be associated with high mortality rates postoperatively. Currently, there are no specific recommendations for the cardiovascular assessment of a potential liver transplant recipient. It seems that a thoughtful preoperative evaluation, as the authors describe, is paramount.Also highlighted in the manuscript, and that which is consistent with current data, is that the Childs class C patients continue to have dismal results regardless of the management strategy. The best predictive scale among the many available, including mean end-stage liver disease, 50–50 criteria, posthepatectomy liver failure, nutritional index, and Child-Turcotte-Pugh, remains unclear. What is clear is that advanced end-stage liver disease is a systemic problem, and even with eliminating liver failure as a postoperative complication, the morbidity and mortality remain high.Fortunately, concurrent with the advancement in technique suggested in this report have come numerous others in cardiovascular medicine. It remains to be seen how such entities as transcatheter valvular therapies, off-pump coronary artery bypass, and hybrid approaches to coronary artery disease may affect the management of the patients with advanced liver disease (Childs C). A bridging strategy with subsequent optimization might prove beneficial in a subset of these patients.Importantly, it does seem that an elective cardiac operation combined with liver transplantation is feasible in the patients with less advanced cirrhosis. Cardiac pathology should be considered only a relative contraindication to liver transplantation. More data are necessary to further define the appropriate selection criteria and management strategy, from both the cardiac and liver failure perspectives. The authors and other investigators should be urged to continue to pursue this endeavor. The morbidity and mortality associated with liver transplantation is significantly increased in patients with cardiac disease, and has especially been the case with coronary occlusive disease. As a result, the presence of untreated cardiac pathology has traditionally been considered a contraindication to liver transplantation. Unfortunately, previous studies have reported that in the presence of cirrhosis, attempts at correction of cardiovascular disease with cardiac surgery similarly carry a high risk of complications or death. Lima and colleagues [1Lima B. Nowicki E.R. Miller C.M. Hashimoto K. Smedira N.G. Gonzalez-Stawinski G.V. Outcomes of simultaneous liver transplantation and elective cardiac surgical procedures.Ann Thorac Surg. 2011; 92: 1580-1585Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] set out to explore whether the combination of elective cardiac surgical operations at the time of liver transplantation would result in improvement of outcomes. Although several previous reports of simultaneous cardiac operations and liver transplantation have been published, this represents the largest series to date. There are several promising findings in this study. When compared with the literature, the outcomes for morbidity and mortality compare favorably with those of patients with cirrhosis undergoing cardiac procedures without concomitant hepatic replacement. This seems to provide, as the authors state, the proof of concept that with the elimination of hepatic dysfunction as a postoperative complication, the surgical outcomes would be improved. Also, the addition of the cardiac surgical procedure did not appear to negatively affect acute or long-term hepatic allograft function. In addition, the presence of cardiac disease did not seem to alter the medium-term survival with respect to the occurrence of adverse cardiac events. As a result, it would seem plausible that many liver transplant programs might reconsider their stance and therapeutic strategies with regard to the presence of cardiac disease in potential recipients. Unfortunately, questions remain in this difficult patient population. As the authors freely admit, this was a highly selected patient group whose requisite variables for eligibility were stringent. Patients with reduced ventricular function and more advanced cardiac pathology were excluded and certainly might have altered the results. The reality is that contemporary liver transplant recipients are presenting with escalating risk profiles. In addition to valvular and coronary artery disease, patients with end-stage liver disease may have an associated cirrhotic cardiomyopathy and portopulmonary hypertension. Neither is a surgical entity, and both may respond only partially to medical management. When severe, they can be associated with high mortality rates postoperatively. Currently, there are no specific recommendations for the cardiovascular assessment of a potential liver transplant recipient. It seems that a thoughtful preoperative evaluation, as the authors describe, is paramount. Also highlighted in the manuscript, and that which is consistent with current data, is that the Childs class C patients continue to have dismal results regardless of the management strategy. The best predictive scale among the many available, including mean end-stage liver disease, 50–50 criteria, posthepatectomy liver failure, nutritional index, and Child-Turcotte-Pugh, remains unclear. What is clear is that advanced end-stage liver disease is a systemic problem, and even with eliminating liver failure as a postoperative complication, the morbidity and mortality remain high. Fortunately, concurrent with the advancement in technique suggested in this report have come numerous others in cardiovascular medicine. It remains to be seen how such entities as transcatheter valvular therapies, off-pump coronary artery bypass, and hybrid approaches to coronary artery disease may affect the management of the patients with advanced liver disease (Childs C). A bridging strategy with subsequent optimization might prove beneficial in a subset of these patients. Importantly, it does seem that an elective cardiac operation combined with liver transplantation is feasible in the patients with less advanced cirrhosis. Cardiac pathology should be considered only a relative contraindication to liver transplantation. More data are necessary to further define the appropriate selection criteria and management strategy, from both the cardiac and liver failure perspectives. The authors and other investigators should be urged to continue to pursue this endeavor. Outcomes of Simultaneous Liver Transplantation and Elective Cardiac Surgical ProceduresThe Annals of Thoracic SurgeryVol. 92Issue 5PreviewMany centers are reticent to list patients for liver transplantation until coexistent cardiac disease is surgically corrected. Previous studies have documented considerable morbidity and mortality in liver failure patients undergoing cardiac operations. This study examined whether elective cardiac operations at the time of hepatic transplantation would yield enhanced outcomes. Full-Text PDF