Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions

Abstract

Liver transplantation (LT) is the second most performed solid organ transplant. Coronary disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors including metabolic dysfunction associated with steatotic liver disease. Presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy.Cardiovascular complications represent the earliest non-graft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. CAD Screening in End-stage Liver Disease is challenging because standard non-invasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using computed tomography (CT) scan is a tool for prediction of cardiovascular events and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both non-contrast and contrast-enhanced chest CT can be used instead of calcium score to assess the presence of coronary calcium.With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention (PCI) could allow shorter duration of dual antiplatelet therapy in simple lesions with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease non-amenable for PCI.The objective of this review is to evaluate existing methods for pre-operative cardiovascular risk stratification and to describe interventions prior to surgery to optimize patient outcomes and reduce cardiovascular event risk.