Multidisciplinary Approach to Cardiac and Pulmonary Vascular Disease Risk Assessment in Liver Transplantation

An Evaluation of the Evidence and Consensus Recommendations

Lisa B. VanWagner; Matthew E. Harinstein; James R. Runo; Christopher Darling; Marina Serper; Shelley Hall; Jon A. Kobashigawa; Laura L. Hammel

Disclosures

American Journal of Transplantation. 2018;18(1):30-42. 

In This Article

Abstract and Introduction

Abstract

Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis, thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

Introduction

Cardiovascular complications are the leading cause of non-graft-related morbidity and mortality early after liver transplantation (LT).[1–3] Accurate risk estimation of cardiovascular complications following LT is paramount to guide allocation of limited resources and improve clinical outcomes. However, patients with end-stage liver disease (ESLD) are poorly represented in current guidelines for preoperative cardiac evaluation and management in noncardiac surgeries.[4,5] This has resulted in significant clinical management variations between transplant programs in the preoperative cardiac evaluation and management decisions of LT candidates when cardiac pathology is identified.

Prevalent cardiovascular disease increases mortality risk, but prognosis might be improved by optimal perioperative management involving multiple disciplines, including hepatology, cardiology, nephrology, pulmonology, anesthesia, critical care, and transplant surgery. It is with this in mind that a working group, endorsed by the American Society of Transplantation (AST) Liver and Intestinal (LICOP) and Thoracic and Critical Care (TCC COP) Communities of Practice, was organized whereby invited experts in the field of transplantation reviewed the diagnostic approaches and treatment strategies that presently exist in the evaluation and management of cardiac and pulmonary vascular disease among patients in need of LT. The goal was to develop a consensus of opinions, based on best available evidence, on optimal practices and to articulate a research agenda to focus on important unanswered questions.

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