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

Valvular Heart Disease

Approximately 28% of LT recipients have evidence of mitral regurgitation, tricuspid regurgitation, or both.[117] Among these patients, intraoperative cardiac output is often increased and systemic vascular resistance significantly decreased with associated increases in intraoperative hypotension requiring vasopressor support.[117] There is conflicting evidence whether the presence of mitral or tricuspid regurgitation affects transplant outcomes.[118,119] One of the hypotheses for this discrepancy is the inability to precisely estimate pulmonary arterial systolic pressure with TTE.

Aortic stenosis (AS) causes pressure overload and hypertrophy of the LV, as well as decreased LV compliance. Significant hemodynamic instability during LT may compromise myocardial perfusion, resulting in ischemia and life-threatening arrhythmias.[83] Data on successful LT in patients with severe AS are sparse, apart from documentation in case reports.[120] Successful transcatheter aortic valve replacement has been performed in patients with moderate ESLD (mean MELD 11) with reasonable outcomes, however, limited data are available in patients with more advanced ESLD.[121] Although the presence of asymptomatic mild to moderate AS is probably not a contraindication to LT, the potential mortality in patients with severe or critical AS may preclude transplantation, unless intervention precedes LT. Transthoracic echocardiography performed intraoperatively may be a useful adjunct in the management of patients with valvular heart disease undergoing LT.

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