S2910 Transcatheter Aortic Valve Replacement Restoring Candidacy for Liver Transplant in Cirrhotic Patients

Abstract

Introduction: Current guidelines for preoperative workup for an orthotopic liver transplant (OLT) recommend echocardiogram and cardiac testing that classically rule-out patients with superimposed severe aortic stenosis as transplant candidates. We evaluated the potential of transcatheter aortic valve replacement (TAVR) as a bridging therapy to restore the candidacy of cirrhotic patients with severe AS for liver transplant. Case Description/Methods: A retrospective chart review was performed on 472 patient records that underwent liver transplants at a single large tertiary care center between 2017 and mid-2021. We identified patients who had a history of severe aortic stenosis corrected by TAVR. We extracted demographic and long-term outcome data. Two patients underwent the TAVR procedure which alleviated AS and allowed for reinstatement of eligibility for OLT. Evaluation at 1-month, 3-months and 1-year post-liver transplant showed no complications in the function of or related to the prosthetic aortic valves. Patient survival at 1 year and 2 years post-transplant was 100%. Mean time of follow-up post-transplant was 27 months. Graft survival at 1 year and 2 years was 100% with no evidence of rejection. Both 1 year and 2-year follow-up labs showed that patients were normotensive and had lipid profiles within the normal range. One of the patients had baseline high HbA1c consistent with their history of type 2 diabetes that continued to show in their follow-up labs while the other had normal glucose and HbA1C throughout. Noteworthy post-transplant complications included a left lower quadrant hematoma in one patient which resolved spontaneously and alcoholic recidivism managed through transplant psychiatry care. One patient did have a left-sided facial droop and right-sided pronator drift two days following the liver transplantation. CTA showed 74% stenosis of the right ICA and MRI confirmed hypoxic ischemia. Facial droop and drift resolved upon revaluation a few hours after onset. (Table) Discussion: In the setting of these growing contraindicated problems of AS and liver cirrhosis, we wanted to contribute to the currently scarce compilation of case reports that illustrates the effect that the TAVR procedure has on relieving the pre-transplantation risks of aortic stenosis in high-risk patients. The patients do have the potential for other cardiovascular diseases long-term and should be monitored closely with modification of risk factors. Table 1. - This is a comparison of echocardiogram parameters of aortic valve morphology and function for both patients #1 and #2 before and after TAVR as well as after OLT Parameters Patient #1 Patient #2 Before TAVR After TAVR After OLT Before TAVR After TAVR After OLT Aortic valve peak gradient (mmhg) 16.9 12.2 16.6 67.7 51.4 50.0 Aortic valves mean gradient (mmhg) 8.4 5.8 9.8 38.3 24.5 25.5 Left ventricular ejection fraction (%) 61 46 55 >70 67 63 Aortic valve area, Vmax (cmÂ2) 2.22 1.53 3.12 0.92 0.98 1.18 The post-TAVR parameters occurred 2 days after the procedure for patient #1 and <6 months for patient #2 due to care referral to our offices. The post OLT echo parameters were measured two months after patient #1's transplant and 4 days after patient #2 transplant.