Abstract
Cardiovascular (CV) complications represent the first non-graft-related cause of death and the third overall cause of death among patients undergoing liver transplantation (LT). History of coronary artery disease is related to increased CV mortality following LT. Although it is of paramount importance to stratify CV risk in pre-LT patients, there is no consensus regarding the choice of the optimal non-invasive cardiac imaging test. Algorithms proposed by scientific associations include non-traditional risk factors, which are associated with increased cardiac risk profiles. Thus, an individualized pre-LT evaluation protocol should be followed. As the average age of patients undergoing LT and the number of candidates continue to rise, the “3 W” questions still remain unanswered, Who, Which and When? Who should be screened for coronary artery disease (CAD), which screening modality should be used and when should the asymptomatic waitlisted patients repeat cardiac evaluation? Prospective studies with large sample sizes are warranted to define an algorithm that can provide better risk stratification and more reliable survival prediction.
Highlights
Liver transplantation (LT) is the second most commonly performed solid organ transplant procedure worldwide, after kidney transplantation [1]
This review focuses on the diagnostic imaging approaches in the evaluation of silent coronary artery disease (CAD) before LT and their efficacy to predict perioperative risk based on current available evidence, as well as on important unanswered questions
Limited accuracy of Dobutamine Stress Echocardiography (DSE) to detect CAD due to: - end-stage liver disease (ESLD) patients typically have hypercontractile left ventricle (LV) - the use of b-blockers results in lower heart rates during the test - the presence of ascites may result in pseudodyskinesis of the posterior wall - microcirculatory disorders
Summary
Liver transplantation (LT) is the second most commonly performed solid organ transplant procedure worldwide, after kidney transplantation [1]. In a meta-analysis of four perioperative studies, Nguyen et al reported that DSE had a sensitivity of 32% and limited accuracy for the detection of CAD among patients with ESLD awaiting liver transplant [14]. They found that the test carried a high negative, but low positive predictive value in predicting outcomes perioperatively and long-term. Nicolau-Raducu et al reported high NPV (89%) and low positive predictive value (PPV, 33%) of DSE for prediction of early cardiac events in 195 patients who achieved the target heart rate on stress test [6].
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