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

Cardiac Dysrhythmias

The impact of pre-existing dysrhythmias on LT outcomes is uncertain. In the past, dysrhythmias were generally felt to be predictors of perioperative complications and poorer outcomes. Subsequent information indicates that this link is related to the severity of the underlying cardiac pathology, rather than the arrhythmia itself.[5,7,103,104]

Atrial fibrillation (AF) is the most commonly encountered tachyarrhythmia,[5,7] with a prevalence ranging from 1% to 6% among LT candidates.[3,4] Patients with pre-existing AF have increased intraoperative and postoperative cardiovascular complications, graft dysfunction, and mortality.[3,105] AF identified during pre-LT evaluation should prompt investigation for other cardiac pathology. Symptomatic patients or those with uncontrolled ventricular response may benefit from a cardiology consultant for management recommendations.[102,106–108] No thromboembolic prophylaxis guidelines for AF exist in patients with ESLD because these patients were not included in clinical studies.[107–109] Despite this, patients with ESLD and AF may present for LT on an oral anticoagulant (eg warfarin or non-Vitamin K oral anticoagulants [NOACs]). The perioperative management and bridging of oral anticoagulants and the decision to reverse them will depend upon the last dose relative to surgery, renal function, risk of thromboembolism, and their anticoagulant activity.[110] Warfarin may be reversed rapidly with Prothrombin Complex Concentrate (PCC). PCC requires significantly less volume than reversal with plasma which is advantageous in patients with ESLD. Plasma and Vitamin K may also be considered for warfarin reversal.

Long QT syndrome, characterized by a rate-corrected QTc of >0.45 seconds in males and >0.47 seconds in females on electrocardiogram, is a disorder of myocardial repolarization and may be either genetic or acquired. In contrast to QT prolongation in the general population, the incidence of sudden cardiac death in ESLD-associated prolonged QT is not elevated.[111] There is, however, an increase in post-LT cardiac events and mortality when QT prolongation is present.[112,113] The mainstay of therapy for prolonged QT interval is β-blockade. In patients with a strong family or personal history of sudden cardiac death related to long QT syndrome, referral to a cardiologist for consideration of implantable defibrillator or other therapy is warranted.[114]

Although a preexisting arrhythmia is not a contraindication to LT, it is essential to rule out underlying cardiac pathology and for the patient to receive appropriate evaluation and management by a cardiologist. LT may be contraindicated in patients with arrhythmias associated with severe HF; hemodynamic instability; structural, valvular, or ischemic heart disease; or those poorly controlled by medical management (Table 1).[5,114–116] In patients with known dysrhythmias, perioperative hemodynamic monitoring with treatment readily at hand, such as transcutaneous or transvenous pacing, electrical cardioversion or defibrillation, and appropriate anti-arrhythmic drugs, is recommended.

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