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Poyekar S, Kapoor D. Pre-Liver Transplant Cardiac Evaluation-Demystifying the Heart Under Stress or Unclogging the Coronaries? J Clin Exp Hepatol 2025; 15:102448. [PMID: 40177698 PMCID: PMC11959372 DOI: 10.1016/j.jceh.2024.102448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 10/21/2024] [Indexed: 04/05/2025] Open
Affiliation(s)
- Samriddhi Poyekar
- Associate Consultant, Transplant Medicine, Yashoda Hospital, Secunderabad, India
| | - Dharmesh Kapoor
- Senior Consultant- Hepatologist, Yashoda Hospital, Secunderabad, India
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Sodoma AM, Pellegrini JR, Greenberg S, Sodoma A, Munshi R, Pellegrini RG, Singh J. Outcomes of Coronary Artery Bypass Grafting (CABG) Patients With and Without a History of Liver Transplant. Cureus 2024; 16:e75820. [PMID: 39822448 PMCID: PMC11737807 DOI: 10.7759/cureus.75820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2024] [Indexed: 01/19/2025] Open
Abstract
BACKGROUND Liver transplant (LT) patients face various challenges, including an increased risk of coronary artery disease (CAD) for a variety of reasons, with 70% of LT recipients having one cardiovascular event. Coronary artery bypass grafting (CABG) remains one of the most commonly performed major surgical procedures in the United States, with 20-30% of LT patients requiring a CABG. Many studies have analyzed when to perform a CABG and CAD workup pre-LT, but this population remains a problem. The patient population is challenging to study due to their rarity and complexity. Our study aimed to compile many patients through the National Inpatient Sample (NIS) database to gauge the outcomes of CABG in patients with and without a history of LT. Methods: Patients who underwent CABG with or without a history of LT were selected from the NIS from 2008 to 2020. The International Classification of Diseases (ICD) 9 and 10 codes were used to identify suitable records. Primary outcomes of interest were all-cause hospital mortality, shock, acute myocardial infarction, acute kidney injury (AKI), and a composite of these. Secondary outcomes included length of stay and total charges. Results: A weighted total of 2,407,349 CABG hospitalizations were included in this study. Of these, 1,833 had a history of LT. Overall, patients with a history of LT were more likely to be younger (65.16 vs. 66.16; p<0.001), male (81.6% vs. 73.66%; p<0.001), and more complex (Charlson Comorbidity Index (CCI) 5.89 vs. 4.16; p<0.001) than patients without a history of LT. Patients with a history of LT also had higher rates of diabetes mellitus type 2 (57.02% vs. 43.39%; p<0.001), end-stage renal disease (11.21% vs. 2.95%; p<0.001), and gastroesophageal reflux disease (GERD) (28.39% vs. 21.26%; p<0.001). CABG patients with a history of LT were less likely, however, to have hyperlipidemia (56.72% vs. 74.26%; p<0.001), hypertension (25.95% vs. 58.45%; p<0.001), obesity (19% vs. 23.42%; p=0.046), a history of smoking (12.06% vs. 18.66%; p<0.01), or alcohol use disorder (9.04% vs. 13.44%; p=0.017). We found that patients admitted for CABG with a history of LT had significantly higher adjusted odds of mortality (OR 1.84; p<0.01), AKI (OR 2.65; p<0.001), and composite outcome (OR 2.04; p<0.001). They also experienced a longer length of stay (1.7 days; p=0.02) and greater hospital charges ($26,761; p=0.029). CONCLUSION We found that CABG patients with a history of LT had nearly twofold higher odds of mortality, nearly threefold higher odds of AKI, and twofold higher odds of composite outcomes than CABG patients without LT. This corresponded to longer lengths of stay and increased hospital charges. Patients should require lower thresholds for left heart catheterization and more strict CAD testing before an LT due to the increased risk of adverse outcomes with the current standard of care.
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Affiliation(s)
- Andrej M Sodoma
- Internal Medicine, South Shore University Hospital, Bay Shore, USA
| | | | - Samuel Greenberg
- Anesthesia and Critical Care, Renaissance School of Medicine at Stony Brook University, Stony Brook, USA
| | - Andrej Sodoma
- Chemistry Faculty, College of Natural Sciences, Grand Canyon University, Phoenix, USA
| | - Rezwan Munshi
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
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Soldera J, Corso LL, Rech MM, Ballotin VR, Bigarella LG, Tomé F, Moraes N, Balbinot RS, Rodriguez S, Brandão ABDM, Hochhegger B. Predicting major adverse cardiovascular events after orthotopic liver transplantation using a supervised machine learning model: A cohort study. World J Hepatol 2024; 16:193-210. [PMID: 38495288 PMCID: PMC10941741 DOI: 10.4254/wjh.v16.i2.193] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/27/2023] [Accepted: 02/04/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Liver transplant (LT) patients have become older and sicker. The rate of post-LT major adverse cardiovascular events (MACE) has increased, and this in turn raises 30-d post-LT mortality. Noninvasive cardiac stress testing loses accuracy when applied to pre-LT cirrhotic patients. AIM To assess the feasibility and accuracy of a machine learning model used to predict post-LT MACE in a regional cohort. METHODS This retrospective cohort study involved 575 LT patients from a Southern Brazilian academic center. We developed a predictive model for post-LT MACE (defined as a composite outcome of stroke, new-onset heart failure, severe arrhythmia, and myocardial infarction) using the extreme gradient boosting (XGBoost) machine learning model. We addressed missing data (below 20%) for relevant variables using the k-nearest neighbor imputation method, calculating the mean from the ten nearest neighbors for each case. The modeling dataset included 83 features, encompassing patient and laboratory data, cirrhosis complications, and pre-LT cardiac assessments. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). We also employed Shapley additive explanations (SHAP) to interpret feature impacts. The dataset was split into training (75%) and testing (25%) sets. Calibration was evaluated using the Brier score. We followed Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for reporting. Scikit-learn and SHAP in Python 3 were used for all analyses. The supplementary material includes code for model development and a user-friendly online MACE prediction calculator. RESULTS Of the 537 included patients, 23 (4.46%) developed in-hospital MACE, with a mean age at transplantation of 52.9 years. The majority, 66.1%, were male. The XGBoost model achieved an impressive AUROC of 0.89 during the training stage. This model exhibited accuracy, precision, recall, and F1-score values of 0.84, 0.85, 0.80, and 0.79, respectively. Calibration, as assessed by the Brier score, indicated excellent model calibration with a score of 0.07. Furthermore, SHAP values highlighted the significance of certain variables in predicting postoperative MACE, with negative noninvasive cardiac stress testing, use of nonselective beta-blockers, direct bilirubin levels, blood type O, and dynamic alterations on myocardial perfusion scintigraphy being the most influential factors at the cohort-wide level. These results highlight the predictive capability of our XGBoost model in assessing the risk of post-LT MACE, making it a valuable tool for clinical practice. CONCLUSION Our study successfully assessed the feasibility and accuracy of the XGBoost machine learning model in predicting post-LT MACE, using both cardiovascular and hepatic variables. The model demonstrated impressive performance, aligning with literature findings, and exhibited excellent calibration. Notably, our cautious approach to prevent overfitting and data leakage suggests the stability of results when applied to prospective data, reinforcing the model's value as a reliable tool for predicting post-LT MACE in clinical practice.
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Affiliation(s)
- Jonathan Soldera
- Post Graduate Program at Acute Medicine and Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
- Postgraduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil.
| | - Leandro Luis Corso
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | - Matheus Machado Rech
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | | | - Fernanda Tomé
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | - Nathalia Moraes
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | - Santiago Rodriguez
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Ajacio Bandeira de Mello Brandão
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Bruno Hochhegger
- Postgraduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
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Rind F, Zhao S, Haring C, Kang SY, Agrawal A, Ozer E, Old MO, Carrau RL, Seim NB. Body Mass Index (BMI) Related Morbidity with Thyroid Surgery. Laryngoscope 2023; 133:2823-2830. [PMID: 37265205 DOI: 10.1002/lary.30789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/19/2023] [Accepted: 05/10/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system. METHODS The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007-2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database. RESULTS The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014-1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01). CONCLUSION Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation. LEVEL OF EVIDENCE 3 Laryngoscope, 133:2823-2830, 2023.
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Affiliation(s)
- Fahad Rind
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
| | - Songzhu Zhao
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Catherine Haring
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephen Y Kang
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Amit Agrawal
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Enver Ozer
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew O Old
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nolan B Seim
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Kharawala A, Safiriyu I, Olayinka A, Hajra A, Seo J, Akunor H, Alhuarrat MAD, Tachil R. Incidence, predictors and outcomes of new onset systolic heart failure following Orthotopic liver transplant: A systematic review. Transplant Rev (Orlando) 2023; 37:100758. [PMID: 37027999 DOI: 10.1016/j.trre.2023.100758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND New onset Systolic heart failure (SHF), characterized by new onset left ventricular (LV) systolic dysfunction with a reduction in ejection fraction (EF) of <40%, is a common cause of morbidity and mortality among Orthotopic liver transplant (OLT) recipients. Therefore, we aimed to evaluate the prevalence, the pre-transplant predictors, and the prognostic impact of SHF post-OLT. METHODS We conducted a systematic review of the literature using electronic databases MEDLINE, Web of Science, and Embase for studies reporting acute systolic heart failure post-liver transplant from inception to August 2021. RESULT Of 2604 studies, 13 met the inclusion criteria and were included in the final systematic review. The incidence of new-onset SHF post OLT ranged from 1.2% to 14%. Race, sex, or body mass index did not significantly impact the post-OLT SHF incidence. Alcoholic liver cirrhosis, pre-transplant systolic or diastolic dysfunction, troponin, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) elevation, and hyponatremia were noted to be significantly associated with the development of SHF post-OLT. The significance of MELD score in the development of post-OLT SHF is controversial. Pre-transplant beta-blocker and post-transplant tacrolimus use were associated with a lower risk of developing SHF. The average 1-year mortality rate in patients with SHF post-OLT ranged from 0.00% to 35.2%. CONCLUSION Despite low incidence, SHF post-OLT can lead to higher mortality. Further studies are required to fully understand the underlying mechanism and risk factors.
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Kalluru R, Gadde S, Chikatimalla R, Dasaradhan T, Koneti J, Cherukuri SP. Cirrhotic Cardiomyopathy: The Interplay Between Liver and Heart. Cureus 2022; 14:e27969. [PMID: 36120195 PMCID: PMC9467492 DOI: 10.7759/cureus.27969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2022] [Indexed: 11/05/2022] Open
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Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, Contreras-Yametti FI, Murthy S, Jorde UP. Cardiac risk stratification of the liver transplant candidate: A comprehensive review. World J Transplant 2022; 12:142-156. [PMID: 36051452 PMCID: PMC9331410 DOI: 10.5500/wjt.v12.i7.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
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Affiliation(s)
- Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
| | - Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
| | | | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
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Development of the AI-Cirrhosis-ECG Score: An Electrocardiogram-Based Deep Learning Model in Cirrhosis. Am J Gastroenterol 2022; 117:424-432. [PMID: 35029163 PMCID: PMC9727935 DOI: 10.14309/ajg.0000000000001617] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cirrhosis is associated with cardiac dysfunction and distinct electrocardiogram (ECG) abnormalities. This study aimed to develop a proof-of-concept deep learning-based artificial intelligence (AI) model that could detect cirrhosis-related signals on ECG and generate an AI-Cirrhosis-ECG (ACE) score that would correlate with disease severity. METHODS A review of Mayo Clinic's electronic health records identified 5,212 patients with advanced cirrhosis ≥18 years who underwent liver transplantation at the 3 Mayo Clinic transplant centers between 1988 and 2019. The patients were matched by age and sex in a 1:4 ratio to controls without liver disease and then divided into training, validation, and test sets using a 70%-10%-20% split. The primary outcome was the performance of the model in distinguishing patients with cirrhosis from controls using their ECGs. In addition, the association between the ACE score and the severity of patients' liver disease was assessed. RESULTS The model's area under the curve in the test set was 0.908 with 84.9% sensitivity and 83.2% specificity, and this performance remained consistent after additional matching for medical comorbidities. Significant elevations in the ACE scores were seen with increasing model for end-stage liver disease-sodium score. Longitudinal trends in the ACE scores before and after liver transplantation mirrored the progression and resolution of liver disease. DISCUSSION The ACE score, a deep learning model, can accurately discriminate ECGs from patients with and without cirrhosis. This novel relationship between AI-enabled ECG analysis and cirrhosis holds promise as the basis for future low-cost tools and applications in the care of patients with liver disease.
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Abstract
Liver transplantation (LT) has revolutionized outcomes for cirrhotic patients. Current liver allocation policies dictate patients with highest short-term mortality receive the highest priority, thus, several patients become increasingly ill on the waitlist. Given cirrhosis is a progressive disease, it can be complicated by the occurrence of acute-on-chronic liver failure (ACLF), a syndrome defined by an acute deterioration of liver function associated with extrahepatic organ failures requiring intensive care support and a high short-term mortality. Successfully bridging to transplant includes accurate prognostication and prioritization of ACLF patients awaiting LT, optimizing intensive care support pre-LT, and tailoring immunosuppressive and anti-infective therapies post-LT. Furthermore, predicting futility (too sick to undergo LT) in ACLF is challenging. In this review, we summarize the role of LT in ACLF specifically highlighting (a) current prognostic scores in ACLF, (b) critical care management of the ACLF patient awaiting LT, (c) donor issues to consider in transplant in ACLF, and (d) exploring of recent post-LT outcomes in ACLF and potential opportunities to improve outcomes including current care gaps and unmet research needs.
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Robertson M, Chung W, Liu D, Seagar R, O'Halloran T, Koshy AN, Horrigan M, Farouque O, Gow P, Angus P. Cardiac Risk Stratification in Liver Transplantation: Results of a Tiered Assessment Protocol Based on Traditional Cardiovascular Risk Factors. Liver Transpl 2021; 27:1007-1018. [PMID: 33606328 DOI: 10.1002/lt.26025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Abstract
Coronary artery disease (CAD) confers increased perioperative risk in patients undergoing liver transplantation (LT). Although routine screening for CAD is recommended, there are limited data on the effectiveness of screening strategies. We evaluated the safety and efficacy of a 3-tiered cardiac risk-assessment protocol that stratifies patients based on age and traditional cardiac risk factors. We peformed a single-center, prospective, observational study of consecutive adult patients undergoing LT assessment (2010-2017). Patients were stratified into low-risk (LR), intermediate-risk (IR), or high-risk (HR) cardiac groups and received standardized investigations with selective use of transthoracic echocardiography (TTE), dobutamine stress echocardiography (DSE), computed tomography coronary angiography (CTCA), and coronary angiography (CA). Primary outcomes were cardiac events (CEs) and cardiovascular death up to 30 days after LT. Overall, 569 patients were included, with 76 patients identified as LR, 256 as IR, and 237 as HR. Cardiac risk factors included diabetes mellitus (26.0%), smoking history (47.3%), hypertension (17.8%), hypercholesterolemia (7.2%), family (17.0%) or prior history of heart disease (6.0%), and obesity (27.6%). Of the patients, 42.0% had ≥2 risk factors. Overall compliance with the protocol was 90.3%. Abnormal findings on TTE, DSE, and CTCA were documented in 3, 23, and 44 patients, respectively, and 12 patients were not listed for transplantation following cardiac assessment (1 LR, 2 IR, and 9 HR). Moderate or severe CAD was identified in 25.4% of HR patients on CTCA following a normal DSE. CEs were recorded in 7 patients (1.2%), with 2 cardiovascular deaths (0.4%). Cardiac risk stratification based on traditional cardiac risk factors with the selective use of DSE, CTCA, and CA is a safe and feasible approach that results in a low perioperative cardiac event rate.
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Affiliation(s)
- Marcus Robertson
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
| | - William Chung
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Dorothy Liu
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rosemary Seagar
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Tess O'Halloran
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Anoop N Koshy
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Cardiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
| | - Peter Angus
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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Doctorian T, Nandkeolyar S, Fearon C, Nayak S, Tryon D, Sakr A, Stoletniy L, De Vera M, Volk M, Abramov D. Utility of Framingham Score for Optimizing Preoperative Evaluation Among Patients Undergoing Liver Transplant Evaluation. Transplant Proc 2021; 53:1616-1621. [PMID: 33965242 DOI: 10.1016/j.transproceed.2021.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cardiac testing of candidates for liver transplant (LT) requires balancing risks and benefits of cardiac procedures. The goal of this study was to evaluate the utility of the Framingham score (FS) for optimizing preoperative risk stratification for coronary artery disease (CAD). METHODS In this single-center retrospective study of 615 adults undergoing LT evaluation from 2016 to 2019, data of preoperative evaluation, post-LT 1-year mortality, and post-LT cardiac events were reviewed. Patients >30 years of age with normal echocardiogram underwent FS calculation. Elevated FS (≥35%) patients were triaged to undergo angiogram for CAD evaluation; FS <35% patients underwent stress testing as initial CAD evaluation. RESULTS Of 615 patients referred for LT, 481 underwent cardiac testing. Ninety-five were excluded from the FS pathway because of age, abnormal baseline echocardiogram, or known CAD. Of the remaining 386 patients in the FS pathway, 342 had a low FS and 44 had a high FS. In patients with low FS, 90% underwent stress testing as initial test; 16% underwent invasive testing at some time. In those with elevated FS, 59% underwent invasive testing as initial test. Listing rate and posttransplant outcomes were similar between patients with low and high FS. CONCLUSION We demonstrated the feasibility of a simple algorithmic evaluation process using FS for optimizing pre-LT risk stratification for CAD. Although exceptions to the protocol occur, the proposed protocol allows for a streamlined approach by prioritizing testing based on cardiac risk. This approach may maximize diagnostic yield while limiting invasive procedures.
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Affiliation(s)
- Tanya Doctorian
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Shuktika Nandkeolyar
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Colleen Fearon
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Srishti Nayak
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - David Tryon
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Antoine Sakr
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Liset Stoletniy
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Michael De Vera
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Michael Volk
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Dmitry Abramov
- Divisions of Cardiology and Liver Transplant, Loma Linda University Medical Center, Loma Linda, California, United States.
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Juneja R, Kumar A, Ranjan R, Hemantlal PM, Mehta Y, Wasir H, Vohra V, Trehan N. Combined off pump coronary artery bypass graft and liver transplant. Ann Card Anaesth 2021; 24:197-202. [PMID: 33884976 PMCID: PMC8253011 DOI: 10.4103/aca.aca_194_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/25/2020] [Accepted: 05/30/2020] [Indexed: 11/27/2022] Open
Abstract
Background Prospective recipients of liver transplant (LT) have a high prevalence rate of coronary artery disease (CAD) requiring revascularization. In patients of Child Turcot Pugh Class B and C performing LT prior to cardiac revascularization on cardiopulmonary bypass leads to a high risk of major adverse cardiovascular events (MACE). Whereas, isolated cardiac surgery prior to LT has perioperative risk of coagulopathy, sepsis, and hepatic decompensation. We present four cases of end stage liver disease who underwent concomitant living donor liver transplant (LDLT) with off pump coronary artery bypass graft (OPCAB) in an effort to decrease the morbidity and mortality. Methods The cases were performed in a tertiary care centre over two years. Four patients scheduled for LDLT, who were diagnosed with significant CAD, underwent single sitting OPCAB and LDLT. Cardiac surgery was performed first and once patient was stable, it was followed by LDLT. The morbidity parameters in terms of duration of intubation, blood transfusion, hospital stay, ICU stay, requirement of dialysis, atrial fibrillation and sepsis was compared with similar studies. Results The blood transfusion requirement (median 8 units PRBC), incidence of atrial fibrillation (25%), sepsis (25%), and renal dysfunction (0%) was less than the combined surgery conducted on cardiopulmonary bypass. The rate of median intubation time, length of ICU stay, hospital stay, and one year mortality rate was comparable with other studies. Conclusions Morbidity with combined OPCAB and LDLT is less than combined on pump coronary artery bypass surgery with LDLT. Combined CABG with LDLT may be performed with acceptable outcomes in CTP class B and C cirrhosis.
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Affiliation(s)
- Rajiv Juneja
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Ajay Kumar
- Department of Anaesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rajeev Ranjan
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - P M Hemantlal
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Yatin Mehta
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Harpreet Wasir
- Medanta Heart Institute, Medanta the Medicity, Rishikesh, Uttarakhand, India
| | - Vijay Vohra
- Institute of Critical Care and Anaesthesia, Medanta-the Medicity, Rishikesh, Uttarakhand, India
| | - Naresh Trehan
- Medanta Heart Institute, Medanta the Medicity, Rishikesh, Uttarakhand, India
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13
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Jain V, Bansal A, Radakovich N, Sharma V, Khan MZ, Harris K, Bachour S, Kleb C, Cywinski J, Argalious M, Quintini C, Menon KVN, Nair R, Tong M, Kapadia S, Fares M. Machine Learning Models to Predict Major Adverse Cardiovascular Events After Orthotopic Liver Transplantation: A Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:2063-2069. [PMID: 33750661 DOI: 10.1053/j.jvca.2021.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/18/2021] [Accepted: 02/01/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop machine learning models that can predict post-transplantation major adverse cardiovascular events (MACE), all-cause mortality, and cardiovascular mortality in patients undergoing liver transplantation (LT). DESIGN Retrospective cohort study. SETTING High-volume tertiary care center. PARTICIPANTS The study comprised 1,459 consecutive patients undergoing LT between January 2008 and December 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS MACE, all-cause mortality, and cardiovascular mortality were modeled using logistic regression, least absolute shrinkage and selection surgery regression, random forests, support vector machine, and gradient-boosted modeling (GBM). All models were built by splitting data into training and testing cohorts, and performance was assessed using five-fold cross-validation based on the area under the receiver operating characteristic curve and Harrell's C statistic. A total of 1,459 patients were included in the final cohort; 1,425 (97.7%) underwent index transplantation, 963 (66.0%) were female, the median age at transplantation was 57 (11-70) years, and the median Model for End-Stage Liver Disease score was 20 (6-40). Across all outcomes, the GBM model XGBoost achieved the highest performance, with an area under the receiver operating curve of 0.71 (95% confidence interval [CI] 0.63-0.79) for MACE, a Harrell's C statistic of 0.64 (95% CI 0.57-0.73) for overall survival, and 0.72 (95% CI 0.59-0.85) for cardiovascular mortality over a mean follow-up of 4.4 years. Examination of Shapley values for the GBM model revealed that on the cohort-wide level, the top influential factors for postoperative MACE were age at transplantation, diabetes, serum creatinine, cirrhosis caused by nonalcoholic steatohepatitis, right ventricular systolic pressure, and left ventricular ejection fraction. CONCLUSION Machine learning models developed using data from a tertiary care transplantation center achieved good discriminant function in predicting post-LT MACE, all-cause mortality, and cardiovascular mortality. These models can support clinicians in recipient selection and help screen individuals who may be at elevated risk for post-transplantation MACE.
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Affiliation(s)
- Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Agam Bansal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Nathan Radakovich
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Vikram Sharma
- Division of Cardiovascular Medicine, University of Iowa, Iowa City, IA
| | | | - Kevin Harris
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Salam Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Cerise Kleb
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jacek Cywinski
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Maged Argalious
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - K V Narayanan Menon
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Ravi Nair
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Maan Fares
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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14
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Chelakkat M, Jacob M, Sebastian S, Paul G, NM A, Joy B, Afsal M. Echocardiographic abnormalities in patients with chronic liver disease: Observations from Thrissur, Kerala, India. MGM JOURNAL OF MEDICAL SCIENCES 2021. [DOI: 10.4103/mgmj.mgmj_84_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Löffler AI, Gonzalez JA, Sundararaman SK, Mathew RC, Norton PT, Hagspiel KD, Kramer CM, Ragosta M, Rogers C, Shah NL, Salerno M. Coronary Computed Tomography Angiography Demonstrates a High Burden of Coronary Artery Disease Despite Low-Risk Nuclear Studies in Pre-Liver Transplant Evaluation. Liver Transpl 2020; 26:1398-1408. [PMID: 32772465 PMCID: PMC9014709 DOI: 10.1002/lt.25869] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/25/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
We investigated the presence and severity of coronary artery disease (CAD) in orthotopic liver transplantation (OLT) candidates using coronary artery calcium score (CACS) and coronary computed tomography angiography (CCTA) as compared with the prevalence of normal and abnormal single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). A total of 140 prospective OLT candidates without known CAD underwent coronary artery calcium (CAC) scans with (n = 77) or without CCTA and coronary computed tomography angiography-derived fractional flow reserve (FFRCT ; n = 57) using a dual-source computed tomography (CT) and were followed for 2.6 ± 1.4 years. Coronary plaque was quantified using the segment-involvement score (SIS) and segment stenosis score (SSS). The mean age was 59 ± 6 years, and 65.0% of patients were male. Mean Agatston CACS was 367 ± 653, and 15.0% of patients had CACSs of 0; 83.6% received a SPECT MPI, of which 95.7% were interpreted as normal/probably normal. By CCTA, 9.1% had obstructive CAD (≥70% stenosis), 67.5% had nonobstructive CAD, and 23.4% had no CAD. Nonobstructive CAD was diffuse with mean SIS 3.0 ± 2.9 and SSS 4.5 ± 5.4. Only 14 patients had high risk-findings (severe 3v CAD, n = 4, CACS >1000 n = 10) that prompted X-ray angiography in 3 patients who had undergone CCTA, resulting in revascularization of a high-risk obstruction in 1 patient who had a normal SPECT study. Patients with end-stage liver disease have a high prevalence of nonobstructive CAD by CCTA, which is undiagnosed by SPECT MPI, potentially underestimating cardiovascular risk. Deferring X-ray angiography unless high-risk CCTA findings are present is a potential strategy for avoiding unnecessary X-ray angiography.
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Affiliation(s)
- Adrián I. Löffler
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Jorge A. Gonzalez
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA,Division of Cardiovascular Disease, Scripps Clinic, La Jolla, CA
| | - Shriram K. Sundararaman
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Roshin C. Mathew
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Patrick T. Norton
- Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Klaus D. Hagspiel
- Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Christopher M. Kramer
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA,Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Michael Ragosta
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA
| | | | - Neeral L. Shah
- Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA
| | - Michael Salerno
- Cardiovascular Division, Departments of Medicine, University of Virginia Health System, Charlottesville, VA,Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA,Biomedical Engineering, University of Virginia Health System, Charlottesville, VA
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16
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El Hadi H, Di Vincenzo A, Vettor R, Rossato M. Relationship between Heart Disease and Liver Disease: A Two-Way Street. Cells 2020; 9:cells9030567. [PMID: 32121065 PMCID: PMC7140474 DOI: 10.3390/cells9030567] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/18/2022] Open
Abstract
In clinical practice, combined heart and liver dysfunctions coexist in the setting of the main heart and liver diseases because of complex cardiohepatic interactions. It is becoming increasingly crucial to identify these interactions between heart and liver in order to ensure an effective management of patients with heart or liver disease to provide an improvement in overall prognosis and therapy. In this review, we aim to summarize the cross-talk between heart and liver in the setting of the main pathologic conditions affecting these organs. Accordingly, we present the clinical manifestation, biochemical profiles, and histological findings of cardiogenic ischemic hepatitis and congestive hepatopathy due to acute and chronic heart failure, respectively. In addition, we discuss the main features of cardiac dysfunction in the setting of liver cirrhosis, nonalcoholic fatty liver disease, and those following liver transplantation.
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Affiliation(s)
- Hamza El Hadi
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
- Department of Medicine, Klinikum Rheine, 48431 Rheine, Germany
| | - Angelo Di Vincenzo
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
| | - Roberto Vettor
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
| | - Marco Rossato
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
- Correspondence: ; Tel.: +39-049-8218747; Fax: +39049-8213332
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17
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Jha AK, Lata S. Liver transplantation and cardiac illness: Current evidences and future directions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:225-241. [PMID: 31975575 DOI: 10.1002/jhbp.715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Contraindications to liver transplantation are gradually narrowing. Cardiac illness and chronic liver disease may manifest independently or may be superimposed on each other due to shared pathophysiology. Cardiac surgery involving the cardiopulmonary bypass in patients with Child-Pugh Class C liver disease is associated with a high risk of perioperative morbidity and mortality. Liver transplantation involves hemodynamic perturbations, volume shifts, coagulation abnormalities, electrolyte disturbances, and hypothermia, which may prove fatal in patients with cardiac illness depending upon the severity. Additionally, cardiovascular complications are the major cause of adverse postoperative outcomes after liver transplantation even in the absence of cardiac pathologies. Clinical decision-making has remained an unsettled issue in these clinical scenarios. The absence of randomized clinical studies has further crippled our endeavours for a consensus on the management of patients with end-stage liver disease with cardiac illness. This review seeks to address this complex clinical setting by gathering information from published literature. The management algorithm in this review may facilitate clinical decision making and augur future research.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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18
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Keskin S, Çiftci O, Moray G, Müderrisoğlu H, Haberal M. MELD-XI Score and Coronary Artery Disease Prevalence and Extent Among In-Hospital Patients With End-Stage Liver Failure Awaiting Transplant. EXP CLIN TRANSPLANT 2020; 18:88-92. [PMID: 32008505 DOI: 10.6002/ect.tond-tdtd2019.p32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant is a life-saving procedure for a variety of end-stage liver diseases. Cardiovascular disorders are among the leading cause of death among patients with end-stage liver disease and those undergoing liver transplant procedures. MELD-XI score is a newly developed score for mortality prediction in patients with end-stage liver failure. In this study, we investigated the relationships among MELD-XI score, total in-hospital mortality, and coronary artery disease severity and extent among patients with end-stage liver failure who were awaiting transplant. MATERIALS AND METHODS We retrospectively reviewed medical records of 121 patients with end-stage liver failure on transplant wait list. Study patients had undergone coronary angiography as part of pretransplant cardiac evaluation. We determined prevalence of coronary artery disease and Gensini score (which indicates extent of coronary artery disease) using coronary angiography and reviewed MELD-XI score and in-hospital mortality rates. We compared MELD-XI score and Gensini score in deceased and surviving patients and correlated both scores with mortality and with each other. RESULTS Of 121 patients, 79 (65.3%) were men; mean age of the study population was 59.6 ± 10.2 years. Twenty-eight patients (23.1%) had coronary artery disease, and 13 (10.7%) had severe coronary artery disease on coronary angiography. Twenty-three patients (19%) died while on the transplant wait list. Gensini score and MELD-XI scores were significantly higher in those who died (P < .05). MELD-XI score, but not Gensini score, was a significant independent predictor of death among patients awaiting liver transplant (hazard ratio = 1.35; 95% confidence interval, 1.04-1.78; P < .05). CONCLUSIONS MELD-XI score independently predicted in-hospital death among patients scheduled to undergo liver transplant. These patients also had increased prevalence and extent of coronary artery disease.
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Affiliation(s)
- Suzan Keskin
- From the Department of Cardiology, Başkent University Faculty of Medicine, Ankara, Turkey
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19
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Duvall WL, Singhvi A, Tripathi N, Henzlova MJ. SPECT myocardial perfusion imaging in liver transplantation candidates. J Nucl Cardiol 2020; 27:254-265. [PMID: 30141170 DOI: 10.1007/s12350-018-1388-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/22/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The optimal cardiovascular evaluation prior to liver transplantation remains controversial and includes stress echocardiography, stress MPI, cardiac CTA, and coronary angiography. This study summarizes our experience of the past decade using SPECT MPI in patients with end-stage liver disease, including patient characteristics, stress testing protocols, test results, the need for repeat testing, and downstream testing. METHODS All patients who underwent a clinically indicated stress SPECT MPI study as part of their pre-liver transplant evaluation from 2004 to 2014 were reviewed from the Nuclear Cardiology database. Results of perfusion imaging, repeat testing, subsequent angiography, and need for revascularization were reviewed. RESULTS A total of 2500 patients were referred for SPECT MPI, of those 111 had known CAD and 271 underwent more than one MPI study. Compared to other patients undergoing stress MPI, pre-liver transplant patients were younger, had fewer cardiac risk factors and lower prevalence of prior cardiac history, and used pharmacologic stress more often. During the study decade, patient age increased, prevalence of hypertension increased and smoking decreased, prevalence of known CAD increased, and the number of abnormal studies decreased. Abnormal perfusion results were present in 7.8% of pre-liver transplant patients compared to 34.3% of all other patients. In a multivariate model, age and lower ejection fraction were associated with an abnormal MPI result. Of the 64 patients who underwent subsequent invasive or non-invasive coronary angiography after an abnormal MPI, obstructive CAD was diagnosed in 25 patients (1.0%), non-obstructive CAD was diagnosed in 23 patients (0.9%), and normal coronaries found in 16 patients (0.6%); a total of 18 (0.7%) of these underwent coronary revascularization. The average time to repeat testing was 27.2 ± 17.9 months. In a multivariate model, younger age and exercise stress were associated with repeat testing. In only 17 patients out of 271 with a normal initial perfusion, the repeat study became abnormal. The use of stress-first imaging was successful in 80% of patients with a reduction in Tc-99m dose from 39.1 to 18.3 mCi. CONCLUSION Abnormal SPECT MPI results in candidates for liver transplantation are infrequent compared to non-liver transplant patients and the incidence of obstructive CAD on subsequent angiography even less. Repeat testing in those on the transplant waiting list after initial normal test results appears to be of limited value. Stress-first protocols may be considered for the majority of these patients to reduce testing time and radiation exposure.
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Affiliation(s)
- W Lane Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
| | - Aditi Singhvi
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Nidhi Tripathi
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Milena J Henzlova
- Division of Cardiology, Mount Sinai School of Medicine, New York, NY, USA
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20
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Ershoff BD, Lee CK, Wray CL, Agopian VG, Urban G, Baldi P, Cannesson M. Training and Validation of Deep Neural Networks for the Prediction of 90-Day Post-Liver Transplant Mortality Using UNOS Registry Data. Transplant Proc 2020; 52:246-258. [PMID: 31926745 DOI: 10.1016/j.transproceed.2019.10.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/22/2019] [Accepted: 10/06/2019] [Indexed: 12/11/2022]
Abstract
Prediction models of post-liver transplant mortality are crucial so that donor organs are not allocated to recipients with unreasonably high probabilities of mortality. Machine learning algorithms, particularly deep neural networks (DNNs), can often achieve higher predictive performance than conventional models. In this study, we trained a DNN to predict 90-day post-transplant mortality using preoperative variables and compared the performance to that of the Survival Outcomes Following Liver Transplantation (SOFT) and Balance of Risk (BAR) scores, using United Network of Organ Sharing data on adult patients who received a deceased donor liver transplant between 2005 and 2015 (n = 57,544). The DNN was trained using 202 features, and the best DNN's architecture consisted of 5 hidden layers with 110 neurons each. The area under the receiver operating characteristics curve (AUC) of the best DNN model was 0.703 (95% CI: 0.682-0.726) as compared to 0.655 (95% CI: 0.633-0.678) and 0.688 (95% CI: 0.667-0.711) for the BAR score and SOFT score, respectively. In conclusion, despite the complexity of DNN, it did not achieve a significantly higher discriminative performance than the SOFT score. Future risk models will likely benefit from the inclusion of other data sources, including high-resolution clinical features for which DNNs are particularly apt to outperform conventional statistical methods.
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Affiliation(s)
- Brent D Ershoff
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, California, United States.
| | - Christine K Lee
- Department of Biomedical Engineering, University of California at Irvine, Irvine, California, United States
| | - Christopher L Wray
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, California, United States
| | - Vatche G Agopian
- Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, University of California at Los Angeles, Los Angeles, California, United States
| | - Gregor Urban
- Department of Computer Science, University of California at Irvine, Irvine, California, United States
| | - Pierre Baldi
- Department of Biomedical Engineering, University of California at Irvine, Irvine, California, United States; Department of Computer Science, University of California at Irvine, Irvine, California, United States
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, California, United States
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21
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Suphathamwit A, Mahawithitwong P. Persistent Severe Bradycardia During Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 34:1881-1884. [PMID: 31899143 DOI: 10.1053/j.jvca.2019.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Aphichat Suphathamwit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Prawej Mahawithitwong
- Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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22
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Feltracco P, Barbieri S, Carollo C, Bortolato A, Michieletto E, Bertacco A, Gringeri E, Cillo U. Early circulatory complications in liver transplant patients. Transplant Rev (Orlando) 2019; 33:219-230. [PMID: 31327573 DOI: 10.1016/j.trre.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy.
| | - Stefania Barbieri
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Cristiana Carollo
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Andrea Bortolato
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Elisa Michieletto
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Alessandra Bertacco
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
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23
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International Liver Transplantation Consensus Statement on End-stage Liver Disease Due to Nonalcoholic Steatohepatitis and Liver Transplantation. Transplantation 2019; 103:45-56. [PMID: 30153225 DOI: 10.1097/tp.0000000000002433] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nonalcoholic steatohepatitis (NASH)-related cirrhosis has become one of the most common indications for liver transplantation (LT), particularly in candidates older than 65 years. Typically, NASH candidates have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient evaluation and selection, waitlist morbidity and mortality, and eventually posttransplant outcomes. The purpose of these guidelines is to highlight specific features commonly observed in NASH candidates and strategies to optimize pretransplant evaluation and waitlist survival. More specifically, the working group addressed the following clinically relevant questions providing recommendations based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system supported by rigorous systematic reviews and consensus: (1) Is the outcome after LT similar to that of other etiologies of liver disease? (2) Is the natural history of NASH-related cirrhosis different from other etiologies of end-stage liver disease? (3) How should cardiovascular risk be assessed in the candidate for LT? Should the assessment differ from that done in other etiologies? (4) How should comorbidities (hypertension, diabetes, dyslipidemia, obesity, renal dysfunction, etc.) be treated in the candidate for LT? Should treatment and monitoring of these comorbidities differ from that applied in other etiologies? (5) What are the therapeutic strategies recommended to improve the cardiovascular and nutritional status of a NASH patient in the waiting list for LT? (6) Is there any circumstance where obesity should contraindicate LT? (7) What is the optimal time for bariatric surgery: before, during, or after LT? (8) How relevant is donor steatosis for LT in NASH patients?
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24
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Park J, Lee J, Kwon A, Choi HJ, Chung HS, Hong SH, Park CS, Choi JH, Chae MS. The 2016 ASE/EACVI recommendations may be able to more accurately identify patients at risk for diastolic dysfunction in living donor liver transplantation. PLoS One 2019; 14:e0215603. [PMID: 31013321 PMCID: PMC6478297 DOI: 10.1371/journal.pone.0215603] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT). Patients and methods A total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency. Results The study population was largely male (68.3%), and the median age was 54 (49–59) years. The median model for end-stage liver disease score was 12 (6–22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations. Conclusions The 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jiyoung Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ami Kwon
- Department of Cardiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Sik Chung
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Ho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Bokarvadia R, Jain M, Kedarisetty C, Varghese J, Venkataraman J. Prevalence and clinical presentation of cirrhotic cardiomyopathy: A single centre experience from southern India. Indian J Gastroenterol 2019; 38:150-157. [PMID: 31115783 DOI: 10.1007/s12664-019-00946-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/13/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are scanty data from India on the prevalence and clinical profile of cirrhotic cardiomyopathy (CCM). AIM To identify the prevalence and clinical presentation of CCM in patients with liver cirrhosis. METHODS Five hundred and eighty-six patients with liver cirrhosis were recruited based on inclusion criteria and evaluated for cardiac parameters using electrocardiography, 2-dimensional echocardiography, dobutamine stress test and coronary angiography as needed. Baseline demographic data, liver biochemistry, endoscopic and radiological findings were recorded in all the patients. Appropriate statistical analyses were performed. RESULTS: Four thousand eight hundred and seventy-seven patients with liver disease were registered during the study period. Five hundred and eighty-six cirrhotic patients had cardiac evaluation as per the study protocol. One hundred fifty-nine had coronary artery disease and were excluded. One hundred and ninety-eight of 427 remaining patients (46.4%) had CCM. The median age of patients with CCM was higher compared with those without CCM (52 years vs. 46 years; p-value < 0.00001). Likewise, cirrhosis-related complications ([isolated or in combination], lower pulse rate [< 60/min] and prolonged corrected QT interval [QTc]; p<0.00001) were more frequent in patients with CCM. After excluding known risk factors for CCM such as alcohol, diabetes, hypothyroidism, hypertension, the true prevalence of CCM was 8.2% (48 out of 586). Hepatotropic viral infections (p 0.03) and prolonged QTc (p 0.0004) were commoner in CCM. CONCLUSION Prevalence of CCM in our setting is 33.8%. CCM is commoner in males and is independent of the etiology of cirrhosis, comorbidity and severity of liver disease. Diastolic dysfunction and prolonged QTc interval are common in CCM.
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Affiliation(s)
- Ravi Bokarvadia
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai, 600 100, India
| | - Mayank Jain
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai, 600 100, India.
| | - Chandankumar Kedarisetty
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai, 600 100, India
| | - Joy Varghese
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai, 600 100, India
| | - Jayanthi Venkataraman
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai, 600 100, India
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Papadodima S, Masia R, Stone JR. Cardiac iron overload following liver transplantation in patients without hereditary hemochromatosis or severe hepatic iron deposition. Cardiovasc Pathol 2019; 40:7-11. [PMID: 30763826 DOI: 10.1016/j.carpath.2018.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/21/2018] [Accepted: 12/21/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cardiac iron overload following liver transplantation in patients without hemochromatosis but with severe hepatic iron deposition has been reported to result in heart failure and/or death in case reports and small case series. However, the frequency and causes of cardiac iron overload following liver transplantation and its relationship to cardiac dysfunction in patients without severe hepatic iron deposition are unclear. METHODS The primary inclusion criteria for this study were liver transplantation followed by autopsy or cardiac transplantation within 1 year. Cases of known hemochromatosis were excluded. Iron stains were performed on left ventricular myocardium from either the autopsy or surgically resected heart, as well as the surgically resected liver. RESULTS Nineteen cases met the study criteria: 18 autopsies and 1 case of cardiac transplantation. None of the resected livers evaluated showed severe iron deposition. Myocardial iron deposition was identified in 7 (37%) of the cases. The presence of myocardial iron deposition was not significantly associated with the grade of hepatic iron deposition, or the pre-liver transplantation serum iron or ferritin levels. However, in the patients with myocardial iron deposition, there were trends toward higher pretransplant transferrin saturation (TSAT) and more units of red blood cells transfused (uRBC). The product of the TSAT multiplied by the uRBC was significantly greater in the patients with myocardial iron deposition [4700 (3100-9800) vs. 680 (400-2300), median (interquartile range), P=.003]. New reduced left ventricular ejection fraction (<50%) following liver transplantation occurred in four of five patients with myocardial iron deposition, compared with zero of eight patients without myocardial iron deposition (P=.007). CONCLUSIONS In this series of patients without severe hepatic iron deposition, cardiac iron overload was associated with cardiac dysfunction following liver transplantation and was related to the product of the pre-liver transplant TSAT multiplied by the number of uRBC transfused during and following the surgery.
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Affiliation(s)
- Stavroula Papadodima
- Department of Forensic Medicine and Toxicology, National and Kapodistrian University of Athens, Athens, Greece
| | - Ricard Masia
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.
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Hamed AE, Elsahar M, Elwan NM, El-Nakeep S, Naguib M, Soliman HH, Ahmed Aboubakr A, AbdelMaqsod A, Sedrak H, Assaad SN, Elwakil R, Esmat G, Salh S, Mostafa T, Mogawer S, Sadek SE, Saber MM, Ezelarab H, Mahmoud AA, Sultan S, El Kassas M, Kamal E, ElSayed NM, Moussa S. Managing diabetes and liver disease association. Arab J Gastroenterol 2018; 19:166-179. [PMID: 30420265 DOI: 10.1016/j.ajg.2018.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/26/2018] [Indexed: 02/05/2023]
Abstract
There is strong association between liver diseases and diabetes (DM) which is higher than expected by a chance association of two very common disorders. It can be classified into three categories: Liver disease related to diabetes, hepatogenous diabetes (HD), and liver disease occurring coincidentally with DM. The criteria for the diagnosis of diabetes associating liver disease are the same for primary diabetes. Two hours post glucose load is a better screening test for HD. HbA1c may not be suitable for diagnosis or monitoring of diabetes associating advanced liver disease. Apart from the increased cardiovascular risk in patients with type 2 DM (T2 DM) and NAFLD, the cardiovascular and retinopathy risk is low in HD. Patients with metabolic derangement should be screened for NAFLD which in turn may predict T2 DM development. Similarly, patients with established T2 DM should also be screened for NAFLD which further contributes to diabetes worsening. Diabetes is a significant risk factor for progression of the chronic liver disease. It is associated with poor patient survival. Treatment of diabetes associating liver disease appears beneficial. Metformin, if tolerated and not contraindicated, is recommended as a first-line therapy for patients with diabetes and chronic liver disease (CLD). If the hepatic disease is severe, insulin secretagogues should be avoided because of the increased risk of hypoglycaemia. Pioglitazone may be useful in patients with fatty liver disease. DPP-4 inhibitors showed effectiveness and safety for the treatment of T2 DM in CLD patients up to those with child B stage. GLP-1 receptor agonists and SGLT-2 inhibitors exhibit positive effects on weight and are associated with minimal risk of hypoglycaemia. Insulin must be used with caution, as hypoglycaemia may be a problem. Insulin analogues are preferred in the context of hypoglycaemia Statins can be used to treat dyslipidaemia in NAFLD, also the use of angiotensin II receptor antagonist for hypertension is safe and beneficial Given the clear association between diabetes mellitus and hepatocellular carcinoma, the strict control of glycaemia with insulin sensitizers can be essential in its prevention. The addition of DM to the currently used scores (Child-Pugh and MELD scores) may enhance the sensitivity and the specificity for prediction of morbidity and mortality rates in cirrhotic patients. In the new era of directly acting antiviral agents (DAAs) for HCV treatment, it is recommended to follow up lipid profile and blood sugar levels following SVR in order to adjust doses of medications used in diabetic (SVR is associated with reduction in insulin requirements) and dyslipidaemic patients (rebound increase in the lipid profile after clearing the virus may increase risk of cardiovascular disease (CVD)). The issues of post liver transplant diabetes and relation between DM and chronic HBV are highlighted. This narrative review and Consensus-based practice guidance (under revision and criticism) are based on a formal review and analysis of the recently published world literature on the topic (Medline search up to September 2017); and the experience of the authors and independent reviewers.
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Affiliation(s)
- Abd Elkhalek Hamed
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt.
| | - Medhat Elsahar
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Police Medical Academy, Egypt
| | | | | | | | | | - Ashraf Ahmed Aboubakr
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | | | - Reda Elwakil
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Ain Shams University, Egypt
| | - Gamal Esmat
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Kasr Al Aini, Egypt
| | - Samira Salh
- Department of Pharmacy, Cairo University, Egypt
| | | | | | - Sameh Emil Sadek
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | - Maha M Saber
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Hanan Ezelarab
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Asem Ashraf Mahmoud
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | - Ehab Kamal
- Medical Department, National Research Centre, Egypt
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, Ungprasert P, Sharma K, Wijarnpreecha K, Pachariyanon P, Cheungpasitporn W. Liver transplantation and atrial fibrillation: A meta-analysis. World J Hepatol 2018; 10:761-771. [PMID: 30386469 PMCID: PMC6206153 DOI: 10.4254/wjh.v10.i10.761] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/24/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess prevalence of pre-existing atrial fibrillation (AF) and/or incidence of AF following liver transplantation, and the trends of patient's outcomes overtime; to evaluate impact of pre-existing AF and post-operative AF on patient outcomes following liver transplantation. METHODS A literature search was conducted utilizing MEDLINE, EMBASE and Cochrane Database from inception through March 2018. We included studies that reported: (1) prevalence of pre-existing AF or incidence of AF following liver transplantation; or (2) outcomes of liver transplant recipients with AF. Effect estimates from the individual study were extracted and combined utilizing random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews, No. CRD42018093644). RESULTS Twelve observational studies with a total of 38586 liver transplant patients were enrolled. Overall, the pooled estimated prevalence of pre-existing AF in patients undergoing liver transplantation was 5.4% (95%CI: 4.9%-5.9%) and pooled estimated incidence of AF following liver transplantation was 8.5% (95%CI: 5.2%-13.6%). Meta-regression analyses were performed and showed no significant correlations between year of study and either prevalence of pre-existing AF (P = 0.08) or post-operative AF after liver transplantation (P = 0.54). The pooled OR of mortality among liver transplant recipients with pre-existing AF was 2.34 (2 studies; 95%CI: 1.10-5.00). In addition, pre-existing AF is associated with postoperative cardiovascular complications among liver transplant recipients (3 studies; OR: 5.15, 95%CI: 2.67-9.92, I 2 = 64%). With limited studies, two studies suggested significant association between new-onset AF and poor clinical outcomes including mortality, cerebrovascular events, post-transplant acute kidney injury, and increased risk of graft failure among liver transplant recipients (P < 0.05). CONCLUSION The overall estimated prevalence of pre-existing AF and incidence of AF following liver transplantation are 5.4% and 8.5%, respectively. Incidence of AF following liver transplant does not seem to decrease overtime. Pre-existing AF and new-onset AF are potentially associated with poor clinical outcomes post liver transplantation.
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Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Division of Cardiovascular Medicine, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Charat Thongprayoon
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, United States
| | - Tarun Bathini
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, United States
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, United States
| | - Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, United States
| | - Pavida Pachariyanon
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, United States.
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Huang S, Peng W, Yang N, Yu T, Cui HY, Xu JY, An Q, Yang H, Liu YN, Li Z, Zuo MZ. Myocardial injury in elderly patients after abdominal surgery. Aging Clin Exp Res 2018; 30:1217-1223. [PMID: 29435832 DOI: 10.1007/s40520-018-0908-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The development of sensitive myocardial-specific cardiac biomarkers allows for detection of very small amounts of myocardial injury or necrosis. Myocardial injury (MI) as a prelude of the serious perioperative complication myocardial infarction, should be paid more attention, especially in elderly susceptible patients. Myocardial injury after abdominal surgery in elderly patients has not been described yet. The objectives of this study were to identify the incidence, predictors, characteristics and the impact of MI on outcome in elderly patients underwent abdominal surgery. METHODS Patients aged ≥ 65 who underwent abdominal surgery longer than 2 h between January 2016 and March 2017 were reviewed. Patients with peak troponin I level of 0.04 ng/ml or greater (abnormal laboratory threshold) within once-administration-period and without non-ischemia troponin elevation proof (e.g., sepsis) were assessed for characteristics and prognosis. Risk factors of MI were determined by multivariable regression. RESULTS Among 285 patients with whole information, 36 patients (12.6%) suffered MI, only 2 patients (0.7%) fulfilled definition of myocardial infarction. With most of them occurred within first 7 days after surgery. Multivariable analysis showed that coronary artery disease (CAD) history [odds ratio (OR) 2.817, P = 0.015], non-laparoscopic surgery (OR 5.181, P = 0.030), blood loss ≥ 800 ml (OR 3.430, P = 0.008), non-venous maintain (OR 2.105, P = 0.047), and infection (OR 4.887, P = 0.008) as risk factors for MI. MI was associated with longer hospital stay (P = 0.006), more cardiac consultation (P = 0.011), higher infection(P = 0.016) and reoperation(P = 0.026) rate. CONCLUSION MI is common in elderly patients who underwent abdominal surgery, while myocardial infarction is infrequent. They are both associated with risk factors and worse prognosis. MI deserves more attention especially in elderly patients. Troponin I measurement is a useful test after massive surgery, which can help risk-stratifying patients, effective preventing, prompt managing and predicting outcomes. Routine monitoring of cardiac biomarkers especially within 7 days after abdominal surgery in elderly patients is recommended.
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Affiliation(s)
- Shun Huang
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China.
| | - WenPing Peng
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
| | - Ning Yang
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China
| | - Tao Yu
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Hong Yuan Cui
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Jing Yong Xu
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Qi An
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Hua Yang
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Yan Nan Liu
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Zhe Li
- Department of Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Ming Zhang Zuo
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People's Republic of China.
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Główczyńska R, Raszeja-Wyszomirska J, Janik M, Kostrzewa K, Zygmunt M, Zborowska H, Krawczyk M, Galas M, Niewińsk G, Krawczyk M, Zieniewicz K, Milkiewicz P, Opolski G. Troponin I Is Not a Predictor of Early Cardiovascular Morbidity in Liver Transplant Recipients. Transplant Proc 2018; 50:2022-2026. [DOI: 10.1016/j.transproceed.2018.02.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 01/06/2023]
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Abstract
INTRODUCTION Liver transplantation has emerged as a successful therapy for end-stage liver disease. However, cardiovascular mortality is the leading cause of fatality in the postoperative period. The aim of this study was to reveal the prevalence and identify risk factors of early cardiovascular events (CVEs). METHODS We performed a retrospective study of all consecutive patients who underwent a primary liver transplantation from 1986 to 2017 (n = 916). We investigated the occurrence of in-hospital CVEs, their predictors, and short- and long-term outcome. RESULTS The prevalence of CVEs was 11%. The adjusted analysis showed that higher age (OR 1.06, 95% CI 1.03-1.09), higher MELD score (OR 1.04, 95% CI 1.01-1.07 CI) and sinus tachycardia at time of screening (OR 3.12, 95% CI 1.45-6.72) were positive predictors for a CVE. Preoperative propranolol use showed a trend towards a higher risk of CVE (OR 1.66, 95% CI 1.00-2.77, p = 0.051). In a sub-analysis of patients where echocardiography data were available (n = 597), a larger left atrial diameter and a higher E/E' ratio were related to early CVEs. Ten-year survival in 30-day survivors was favourable (68.6%; 56.0% vs. 69.8% in the CVE+ vs. the CVE-group, respectively, p = 0.056). DISCUSSION In conclusion, besides known risk factors (age and MELD score), sinus tachycardia (related to the presence of acute liver failure and cirrhosis) was an independent predictor for CVE after liver transplantation.
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Herborn J, Lewis C, De Wolf A. Liver Transplantation: Perioperative Care and Update on Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Darstein F, Hoppe-Lotichius M, Vollmar J, Weyer-Elberich V, Zimmermann A, Mittler J, Otto G, Lang H, Galle PR, Zimmermann T. Pretransplant coronary artery disease is a predictor for myocardial infarction and cardiac death after liver transplantation. Eur J Intern Med 2018; 51:41-45. [PMID: 29229303 DOI: 10.1016/j.ejim.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 11/20/2017] [Accepted: 12/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular disease is a serious problem of liver transplant (LT) recipients because of increased cardiovascular risk due to immunosuppressive therapy, higher age, intraoperative risk and comorbidities (such as diabetes and nicotine abuse). Reported frequency of cardiovascular events after LT shows a high variability between different LT cohorts. Our aim was to analyze a cohort of LT recipients from a single center in Germany to evaluate frequency of the cardiovascular endpoints (CVE) myocardial infarction and/or cardiac death after LT and to investigate correlations of CVE post LT with pretransplant patient characteristics. PATIENTS In total, data from 352 LT patients were analyzed. Patients were identified from an administrative transplant database, and all data were retrieved from patients' charts and reports. RESULTS During the median follow-up of 4.0 (0-13) years, 10 cases of CVE were documented (six myocardial infarctions and four coronary deaths). The frequency of CVE did not differ according to classic cardiovascular risk factors such as body mass index (p=0.071), total cholesterol (p=0.533), hypertension (p=0.747), smoking (p=1.000) and pretransplant diabetes mellitus (p=0.146). In patients with pretransplant coronary heart disease (n=24; 6.8%) CVE were found more frequently (p=0.024). CONCLUSION In summary, we found a rate of 2.8% CVE after LT in a German transplant cohort. Pretransplant CHD was the only risk factor for CVE, but showed no significant impact on overall survival.
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Affiliation(s)
- F Darstein
- First Department of Internal Medicine, Gastroenterology and Hepatology, Universitätsmedizin Mainz, Mainz, Germany.
| | - M Hoppe-Lotichius
- Department of Hepatobiliary and Transplantation Surgery, Universitätsmedizin Mainz, Mainz, Germany
| | - J Vollmar
- First Department of Internal Medicine, Gastroenterology and Hepatology, Universitätsmedizin Mainz, Mainz, Germany
| | - V Weyer-Elberich
- Division of Biostatistics and Bioinformatics, Universitätsmedizin Mainz, Mainz, Germany
| | - A Zimmermann
- First Department of Internal Medicine, Endocrinology and Metabolic Diseases, Universitätsmedizin Mainz, Mainz, Germany
| | - J Mittler
- Department of Hepatobiliary and Transplantation Surgery, Universitätsmedizin Mainz, Mainz, Germany
| | - G Otto
- Department of Hepatobiliary and Transplantation Surgery, Universitätsmedizin Mainz, Mainz, Germany
| | - H Lang
- Department of Hepatobiliary and Transplantation Surgery, Universitätsmedizin Mainz, Mainz, Germany
| | - P R Galle
- First Department of Internal Medicine, Gastroenterology and Hepatology, Universitätsmedizin Mainz, Mainz, Germany
| | - T Zimmermann
- First Department of Internal Medicine, Gastroenterology and Hepatology, Universitätsmedizin Mainz, Mainz, Germany.
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VanWagner LB, Ning H, Whitsett M, Levitsky J, Uttal S, Wilkins JT, Abecassis MM, Ladner DP, Skaro AI, Lloyd-Jones DM. A point-based prediction model for cardiovascular risk in orthotopic liver transplantation: The CAR-OLT score. Hepatology 2017; 66:1968-1979. [PMID: 28703300 PMCID: PMC5696007 DOI: 10.1002/hep.29329] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease (CVD) complications are important causes of morbidity and mortality after orthotopic liver transplantation (OLT). There is currently no preoperative risk-assessment tool that allows physicians to estimate the risk for CVD events following OLT. We sought to develop a point-based prediction model (risk score) for CVD complications after OLT, the Cardiovascular Risk in Orthotopic Liver Transplantation risk score, among a cohort of 1,024 consecutive patients aged 18-75 years who underwent first OLT in a tertiary-care teaching hospital (2002-2011). The main outcome measures were major 1-year CVD complications, defined as death from a CVD cause or hospitalization for a major CVD event (myocardial infarction, revascularization, heart failure, atrial fibrillation, cardiac arrest, pulmonary embolism, and/or stroke). The bootstrap method yielded bias-corrected 95% confidence intervals for the regression coefficients of the final model. Among 1,024 first OLT recipients, major CVD complications occurred in 329 (32.1%). Variables selected for inclusion in the model (using model optimization strategies) included preoperative recipient age, sex, race, employment status, education status, history of hepatocellular carcinoma, diabetes, heart failure, atrial fibrillation, pulmonary or systemic hypertension, and respiratory failure. The discriminative performance of the point-based score (C statistic = 0.78, bias-corrected C statistic = 0.77) was superior to other published risk models for postoperative CVD morbidity and mortality, and it had appropriate calibration (Hosmer-Lemeshow P = 0.33). CONCLUSION The point-based risk score can identify patients at risk for CVD complications after OLT surgery (available at www.carolt.us); this score may be useful for identification of candidates for further risk stratification or other management strategies to improve CVD outcomes after OLT. (Hepatology 2017;66:1968-1979).
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Affiliation(s)
- Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
- Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine
| | - Hongyan Ning
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Maureen Whitsett
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
| | - Josh Levitsky
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
- Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine
- Department of Surgery, Division of Organ Transplantation, Northwestern University Feinberg School of Medicine
| | - Sarah Uttal
- Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine
| | - John T. Wilkins
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine
| | - Michael M. Abecassis
- Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine
- Department of Surgery, Division of Organ Transplantation, Northwestern University Feinberg School of Medicine
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine
- Department of Surgery, Division of Organ Transplantation, Northwestern University Feinberg School of Medicine
| | - Anton I. Skaro
- Department of Surgery, Division of General Surgery and Multi-Organ Transplant, University of Western Ontario Schulich School of Medicine & Dentistry
| | - Donald M. Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine
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Shukla A, Bhatt P, Gupta DK, Modi T, Patel J, Phadke M, Rathod K, Meshram M, Bhatia SJ. Cirrhotic cardiomyopathy is less prevalent in patients with Budd-Chiari syndrome than cirrhosis of liver. Indian J Gastroenterol 2017; 36:474-480. [PMID: 29368192 DOI: 10.1007/s12664-017-0811-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 12/20/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Cirrhotic cardiomyopathy (CCM) is associated with high mortality after transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation in patients with cirrhosis. There is no data about the prevalence or impact of CCM in Budd-Chiari syndrome (BCS). We assessed the prevalence of CCM in patients with BCS and its impact on outcome after radiological intervention. METHODS Thirty-three consecutive patients with BCS (15 men) and 33 controls with hepatitis B-related cirrhosis (18 men, matched for Child-Pugh score) were evaluated with baseline electrocardiography (ECG), echocardiography (ECHO) and dobutamine stress ECHO, and ECG (DSE). The two groups were compared for prevalence of CCM. Patients with BCS with and without CCM were assessed for development of heart failure, duration of intensive care unit (ICU) stay, and in-hospital mortality immediately after radiological intervention. RESULTS Fewer patients with BCS had CCM (7/21 vs. 21/33; p = 0.001, OR-0.16, CI [0.05-0.5]), diastolic dysfunction (DD) (0/33 vs. 6/33; p = 0.01, OR-0.06, CI [0.00-1.1]), and prolonged QTc interval (5/33 vs.17/33; p = 0.001, OR-0.16, CI [0.05-0.5]) despite correction for age. Patients with BCS had lower end-systolic and end-diastolic volumes of left and right ventricles. None of the 19 patients (five with CCM) with BCS undergoing radiological intervention (12 TIPS, 4 inferior vena cava, and 3 hepatic vein stenting) developed heart failure or had prolonged ICU stay. There was no in-hospital mortality. CONCLUSION Patients with BCS have lower frequency of CCM as compared to patients with cirrhosis. CCM may not adversely affect outcomes after radiological interventions.
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Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India.
| | - Pratin Bhatt
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India
| | - Deepak Kumar Gupta
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India
| | - Tejas Modi
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India
| | - Jatin Patel
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India
| | - Milind Phadke
- Department of Cardiology, Seth G S Medical College and KEM Hospital, Parel, Mumbai, 400 012, India
| | - Krantikumar Rathod
- Department of Interventional Radiology, Seth G S Medical College and KEM Hospital, Parel, Mumbai, 400 012, India
| | - Megha Meshram
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India
| | - S J Bhatia
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Room 1120, Multistory Building, 11th floor, Parel, Mumbai, 400 012, India
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Abstract
Liver transplantation (LT) is a unique surgical procedure that has major hemodynamic and cardiovascular implications. Recently, there has been significant interest focused on cardiovascular issues that affect LT patients in all phases of the perioperative period. The preoperative cardiac evaluation is a major step in the selection of LT candidates. LT candidates are aging in concordance with the general population; cardiovascular disease and their risk factors are highly associated with older age. Underlying cardiovascular disease has the potential to affect outcomes in LT patients and has a major impact on candidate selection. The prolonged hemodynamic and metabolic instability during LT may contribute to adverse outcomes, especially in patients with underlying cardiovascular disease. Cardiovascular events are not unusual during LT; transplant anesthesiologists must be prepared for these events. Advanced cardiovascular monitoring techniques and treatment modalities are now routinely used during LT. Postoperative cardiovascular complications are common in both the early and late posttransplant periods. The impact of cardiac complications on posttransplant mortality is well recognized. Emerging knowledge regarding cardiovascular disease in LT patients and its impact on posttransplant outcomes will have an important role in guiding the future perioperative management of LT patients.
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Incidence of and Risk Assessment for Adverse Cardiovascular Outcomes After Liver Transplantation: A Systematic Review. Transplantation 2017; 101:1645-1657. [PMID: 28296809 DOI: 10.1097/tp.0000000000001710] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cardiovascular events represent a major source of morbidity and mortality after liver transplantation and will likely increase given the aging population and nonalcoholic fatty liver disease as a leading indication for transplant. The optimal cardiovascular risk stratification approach in this evolving patient population remains unclear. The aims of this systematic review are to: (1) refine the definition, (2) characterize the incidence, and (3) identify risk factors for cardiovascular events post-liver transplantation. Additionally, we evaluated performance characteristics of different cardiac testing modalities. METHODS MEDLINE via PubMed, EMBASE, Web of Science, and Scopus were searched for studies published between 2002 and 2016 (model of end-stage liver disease era). Two authors independently reviewed articles to select eligible studies and performed data abstraction. RESULTS Twenty-nine studies representing 57 493 patients from 26 unique cohorts were included. Definitions of cardiovascular outcomes were highly inconsistent. Incidence rates were widely variable: 1% to 41% for outcomes of 6 months or shorter and 0% to 31% for outcomes longer than 6 months. Multivariate analyses demonstrated that older age and history of cardiac disease were the most consistent predictors of cardiovascular events posttransplant (significant in 8/23 and 7/22, studies, respectively). Predictive capacity of various cardiac imaging modalities was also discrepant. CONCLUSIONS The true incidence of cardiovascular outcomes post-liver transplant remains unknown in large part due to lack of consensus regarding outcome definition. Overall, poor data quality and gaps in knowledge limit the ability to clearly identify predictors of outcomes, but existing data support a more aggressive risk stratification protocol for patients of advanced age and/or with preexisting cardiac disease.
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Liu H, Jayakumar S, Traboulsi M, Lee SS. Cirrhotic cardiomyopathy: Implications for liver transplantation. Liver Transpl 2017; 23:826-835. [PMID: 28407402 DOI: 10.1002/lt.24768] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/23/2017] [Indexed: 12/12/2022]
Abstract
The majority of patients on a waiting list for liver transplantation have end-stage liver disease. Because of the marked peripheral vasodilatation of end-stage cirrhosis that masks a latent myocardial dysfunction, cardiac abnormalities in the resting state are usually subclinical and escape the attention of physicians. However, when challenged, the systolic and diastolic contractile responses are attenuated. In addition to these contractile abnormalities, morphological changes, such as enlargement or hypertrophy of cardiac chambers, and electrophysiological repolarization changes, including a prolonged QT interval, can be observed. The constellation of these cardiac abnormalities is termed cirrhotic cardiomyopathy. Liver transplantation induces significant cardiovascular stress. Clamping of the inferior vena cava and portal vein, hemorrhage and blood/volume infusion, and ischemia/reperfusion all cause hemodynamic fluctuation. The changing cardiac preload and afterload status increases the cardiac workload, and thus, the previously subclinical ventricular dysfunction may manifest as overt heart failure during the operative and perioperative periods. Cardiac dysfunction contributes to morbidity and mortality associated with liver transplantation. Cardiovascular events are the third leading cause of death in liver recipients. However, because liver transplantation is the only definitive treatment for end-stage liver failure and also appears to reverse cardiac abnormalities, it is important to understand the challenges of the heart in liver transplantation. This review focuses on cardiac status before, during, and after liver transplantation. Liver Transplantation 23 826-835 2017 AASLD.
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Affiliation(s)
- Hongqun Liu
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Saumya Jayakumar
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mouhieddin Traboulsi
- Division of Cardiology and Libin Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Samuel S Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Abstract
Indications for liver transplant have been extended, and older and sicker patients are undergoing transplantation. Infectious, malignant, and cardiovascular diseases account for the most posttransplant deaths. Cirrhotic patients can develop heart disease through systemic diseases affecting the heart and the liver, cirrhosis-specific heart disease, or common cardiovascular. No single factor can predict posttransplant cardiovascular complications. Patients with history of cardiovascular disease, and specific abnormalities on echocardiography, electrocardiography, or serum markers of heart disease seem to be at increased risk of complications. Pretransplant cardiovascular evaluation is essential to detecting these risk factors so their effects can be mitigated through appropriate intervention.
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40
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Muderrisoglu H, Yilmaz KC, Karacaglar E, Bal U, Aydinalp A, Moray G, Haberal M. Preoperative Cardiac Risk Assessment in Patients Undergoing Liver Transplant Due to Hepatocellular Carcinoma: Should It Be Different? EXP CLIN TRANSPLANT 2017; 15:65-68. [PMID: 28302002 DOI: 10.6002/ect.tond16.l17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant is a high-risk surgery for cardiac events. The risk of 30-day major cardiac adverse events is estimated at more than 5%. In this retrospective study, we evaluated our preoperative cardiac risk assessment approach. MATERIALS AND METHODS We evaluated 58 adult patients who underwent liver transplant between May 2011 and May 2015. Preoperative cardiac risk factors and results of diagnostic tests were noted. Patients were divided into 2 groups: patients with or without hepatocellular carcinoma. Electrocardiogram, echocardiogram, and treadmill tests were performed for preoperative cardiac evaluation in all candidates for liver transplant. Results of these tests showed our preference for myocardial perfusion scintigraphy and/or coronary angiography and heart catheterization. RESULTS Mean age of patients was 46.5 ± 14.5 years. The most common cardiovascular risk factor was family history of coronary artery disease (24.1%) in all patients. Diabetes mellitus (15.5%) was the most common risk factor in the patient group without hepatocellular carcinoma. Three patients had already known coronary artery disease (5.2%). Of 16 patients (27.6%) who underwent coronary angiography, 4 were in the hepatocellular carcinoma group. Coronary revascularization by stent implantation was necessary for 1 patient in the hepatocellular carcinoma group; 1 patient in the group without hepatocellular carcinoma underwent preoperative coronary bypass surgery. CONCLUSIONS No consensus exists for cardiovascular risk stratification and preoperative cardiovascular evaluation of liver transplant candidates. Noninvasive stress tests are not always feasible for all liver transplant candidates because of poor mobility and poor exercise capacity. With early diagnoses of cardiovascular conditions and preventive recommendations, liver transplant can be performed safely before spread of the disease, which is essential for carcinoma patients. Angiographic evaluation of liver transplant candidates for hepatocellular carcinoma is strongly recommended.
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Affiliation(s)
- Haldun Muderrisoglu
- Cardiology Department, Baskent University Faculty of Medicine, Ankara, Turkey
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Hogan BJ, Gonsalkorala E, Heneghan MA. Evaluation of coronary artery disease in potential liver transplant recipients. Liver Transpl 2017; 23:386-395. [PMID: 27875636 DOI: 10.1002/lt.24679] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022]
Abstract
Improvements in the management of patients undergoing liver transplantation (LT) have resulted in a significant increase in survival in recent years. Cardiac disease is now the leading cause of early mortality, and the stress of major surgery, hemodynamic shifts, and the possibilities of hemorrhage or reperfusion syndrome require the recipient to have good baseline cardiac function. The prevalence of coronary artery disease (CAD) is increasing in LT candidates, especially in those with nonalcoholic fatty liver disease. In assessing LT recipients, we suggest a management paradigm of "quadruple assessment" to include (1) history, examination, and electrocardiogram; (2) transthoracic echocardiogram; (3) functional testing; and (4) where appropriate, direct assessment of CAD. The added value of functional testing, such as cardiopulmonary exercise testing, has been shown to be able to predict posttransplant complications independently of the presence of CV disease. This approach gives the assessment team the greatest chance of detecting and preventing complications related to CAD. Liver Transplantation 23 386-395 2017 AASLD.
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Affiliation(s)
- Brian J Hogan
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
| | - Enoka Gonsalkorala
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
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Coronary Computed Tomography Angiography in Combination with Coronary Artery Calcium Scoring for the Preoperative Cardiac Evaluation of Liver Transplant Recipients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4081525. [PMID: 28164120 PMCID: PMC5259617 DOI: 10.1155/2017/4081525] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/07/2016] [Accepted: 12/18/2016] [Indexed: 02/08/2023]
Abstract
Liver transplantation is the best treatment option for early-stage hepatocellular carcinoma, liver cirrhosis, fulminant liver failure, and end-stage liver diseases. Even though advances in surgical techniques and perioperative care have improved postoperative outcomes, perioperative cardiovascular complications are a leading cause of postoperative morbidity and mortality following liver transplantation. Ischemic coronary artery disease (CAD) and cardiomyopathy are the most common cardiovascular diseases and could be negative predictors of postoperative outcomes in liver transplant recipients. Therefore, comprehensive cardiovascular evaluations are required to assess perioperative risks and prevent concomitant cardiovascular complications that would preclude good outcomes in liver transplant recipients. The two major types of cardiac computed tomography are the coronary artery calcium score (CACS) and coronary computed tomography angiography (CCTA). CCTA in combination with the CACS is a validated noninvasive alternative to coronary angiography for diagnosing and grading the severity of CAD. A CACS > 400 is associated with significant CAD and a known important predictor of posttransplant cardiovascular complications in liver transplant recipients. In this review article, we discuss the usefulness, advantages, and disadvantages of CCTA combined with CACS as a noninvasive diagnostic tool for preoperative cardiac evaluation and for maximizing the perioperative outcomes of liver transplant recipients.
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Donovan RJ, Choi C, Ali A, Heuman DM, Fuchs M, Bavry AA, Jovin IS. Perioperative Cardiovascular Evaluation for Orthotopic Liver Transplantation. Dig Dis Sci 2017; 62:26-34. [PMID: 27830409 DOI: 10.1007/s10620-016-4371-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/01/2016] [Indexed: 01/01/2023]
Abstract
Patients with advanced liver disease have a high prevalence of cardiovascular risk factors, but many of them are asymptomatic. Cardiovascular risk stratification prior to liver transplant can be done by dobutamine stress echocardiography, stress myocardial perfusion imaging, cardiac computer tomography, and coronary angiography, but there are no clear recommendations regarding what method should be used and who should be screened. Because of this and because of inherent risk profile in this population, the variations in practice are significant. Careful screening and rigorous management of cardiovascular risk factors are important to ensure optimal cardiovascular outcomes in the immediate post-transplantation period and in the long term as well.
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Affiliation(s)
- Robert J Donovan
- Department of Medicine, Virginia Commonwealth University, McGuire VAMC, Richmond, VA, USA
| | - Calvin Choi
- Department of Medicine, Randall VAMC, University of Florida, Gainesville, FL, USA
| | - Asghar Ali
- Department of Medicine, Virginia Commonwealth University, McGuire VAMC, Richmond, VA, USA.
| | - Douglas M Heuman
- Department of Medicine, Virginia Commonwealth University, McGuire VAMC, Richmond, VA, USA
| | - Michael Fuchs
- Department of Medicine, Virginia Commonwealth University, McGuire VAMC, Richmond, VA, USA
| | - Anthony A Bavry
- Department of Medicine, Randall VAMC, University of Florida, Gainesville, FL, USA
| | - Ion S Jovin
- Department of Medicine, Virginia Commonwealth University, McGuire VAMC, Richmond, VA, USA
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45
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Skaro AI, Gallon LG, Lyuksemburg V, Jay CL, Zhao L, Ladner DP, VanWagner LB, De Wolf AM, Flaherty JD, Levitsky J, Abecassis MM, Gheorghiade M. The impact of coronary artery disease on outcomes after liver transplantation. J Cardiovasc Med (Hagerstown) 2016; 17:875-885. [DOI: 10.2459/jcm.0000000000000207] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Huang S, Apinyachon W, Agopian VG, Wray CL, Busuttil RW, Steadman RH, Xia VW. Myocardial injury in patients with hemodynamic derangements during and/or after liver transplantation. Clin Transplant 2016; 30:1552-1557. [PMID: 27653509 DOI: 10.1111/ctr.12855] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 01/14/2023]
Abstract
Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT between 2006 and 2013 were studied. Of 502 patients, 203 (40.4%) met the diagnostic criteria (cTn I ≥0.1 ng/mL) of myocardial injury. The majority of myocardial injury occurred within the first three postoperative days and presented without clinical signs or symptoms of myocardial infarction. Thirty-day mortality in patients with myocardial injury was 11.4%, significantly higher compared with that in patients without myocardial injury (3.4%, P<.01). Cox analysis indicated the peak cTn was significantly associated with 30-day mortality. Multivariable logistic analysis identified three independent risk factors: requirement of ventilation before transplant (odds ratios (OR) 1.6, P=.006), RBC≥15 units (OR 1.7, P=.006), and the presence of PRS (OR 2.0, P=.028). We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.
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Affiliation(s)
- Shun Huang
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing, China.,Department of Anesthesiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Worapot Apinyachon
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vatche G Agopian
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christopher L Wray
- Department of Anesthesiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Randolph H Steadman
- Department of Anesthesiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Victor W Xia
- Department of Anesthesiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Licata A, Novo G, Colomba D, Tuttolomondo A, Galia M, Camma' C. Cardiac involvement in patients with cirrhosis: a focus on clinical features and diagnosis. J Cardiovasc Med (Hagerstown) 2016; 17:26-36. [PMID: 26065511 DOI: 10.2459/jcm.0000000000000288] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cirrhotic heart has been traditionally considered protected from cardiovascular disease, even if a large amount of literature has recently shown that patients affected by chronic liver disease are exposed to cardiovascular events, as well. Since the first recognition of cardiac involvement in cirrhosis, all published studies explain that decompensated cirrhotic patients suffer from haemodynamic changes, currently known as hyperdynamic syndrome, which finally lead to cirrhotic cardiomyopathy. This is defined by the presence of a subclinical systolic dysfunction unmasked under stress conditions, impaired diastolic function and electrophysiological abnormalities, in the absence of any known cardiac disease. In this review, we will discuss the clinical and diagnostic features of this condition, the prevalence of associated comorbidities, echocardiographic, electrocardiographic and cardiac magnetic resonance hallmarks and the possible diagnostic role of serum biomarkers.
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Affiliation(s)
- Anna Licata
- aSezione di Gastroenterologia ed Epatologia bSezione di Medicina Clinico-Sperimentale, Dipartimento di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Italy cDivisione di Cardiologia dSezione di Radiologia, Dipartimento di Biopatologia e Biotecnologie Mediche, DiBiMEF, Università di Palermo, Palermo, Italy
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Nonalcoholic fatty liver: optimizing pretransplant selection and posttransplant care to maximize survival. Curr Opin Organ Transplant 2016; 21:99-106. [PMID: 26825357 DOI: 10.1097/mot.0000000000000283] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Nonalcoholic steatohepatitis (NASH) is projected to become the most common indication for liver transplantation in the near future. NASH recipients have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient selection, posttransplant morbidity and potentially long-term outcomes. The purpose of this review is to highlight strategies to optimize pretransplant selection, outcomes, and posttransplant risk modification to optimize patient and graft survival. RECENT FINDINGS NASH recipients are at risk for pretransplant cardiovascular disease, diabetes mellitus, and related renovascular complications. Stringent selection criteria identify those patients most likely to benefit from liver transplantation without adverse cardiovascular events yet, the incidence of these events remains high in NASH recipients. High BMI imparts postoperative morbidity because of infections, wound complications, and longer lengths of hospital stay. Aggressive management of modifiable risk factors such as obesity, hyperlipidemia, diabetes mellitus, and hypertension is recommended. SUMMARY Although patient and graft survival in NASH recipients is excellent, long-term reduction in healthcare utilization and outcomes in these patients would benefit from risk factor modification. Periodic reassessment of coronary artery disease and early consideration of bariatric surgery is recommended in this population.
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VanWagner LB, Serper M, Kang R, Levitsky J, Hohmann S, Abecassis M, Skaro A, Lloyd-Jones DM. Factors Associated With Major Adverse Cardiovascular Events After Liver Transplantation Among a National Sample. Am J Transplant 2016; 16:2684-94. [PMID: 26946333 PMCID: PMC5215909 DOI: 10.1111/ajt.13779] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 02/19/2016] [Accepted: 02/25/2016] [Indexed: 01/25/2023]
Abstract
Assessment of major adverse cardiovascular events (MACE) after liver transplantation (LT) has been limited by the lack of a multicenter study with detailed clinical information. An integrated database linking information from the University HealthSystem Consortium and the Organ Procurement and Transplant Network was analyzed using multivariate Poisson regression to assess factors associated with 30- and 90-day MACE after LT (February 2002 to December 2012). MACE was defined as myocardial infarction (MI), heart failure (HF), atrial fibrillation (AF), cardiac arrest, pulmonary embolism, and/or stroke. Of 32 810 recipients, MACE hospitalizations occurred in 8% and 11% of patients at 30 and 90 days, respectively. Recipients with MACE were older and more likely to have a history of nonalcoholic steatohepatitis (NASH), alcoholic cirrhosis, MI, HF, stroke, AF and pulmonary and chronic renal disease than those without MACE. In multivariable analysis, age >65 years (incidence rate ratio [IRR] 2.8, 95% confidence interval [95% CI] 1.8-4.4), alcoholic cirrhosis (IRR 1.6, 95% CI 1.2-2.2), NASH (IRR 1.6, 95% CI 1.1-2.4), pre-LT creatinine (IRR 1.1, 95% CI 1.04-1.2), baseline AF (IRR 6.9, 95% CI 5.0-9.6) and stroke (IRR 6.3, 95% CI 1.6-25.4) were independently associated with MACE. MACE was associated with lower 1-year survival after LT (79% vs. 88%, p < 0.0001). In a national database, MACE occurred in 11% of LT recipients and had a negative impact on survival. Pre-LT AF and stroke substantially increase the risk of MACE, highlighting potentially high-risk LT candidates.
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Affiliation(s)
- L B VanWagner
- Division of Gastroenterology & Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - M Serper
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - R Kang
- Center for Heathcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J Levitsky
- Division of Gastroenterology & Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - S Hohmann
- University HealthSystem Consortium, Chicago, IL
- Rush University Health Systems Management Department, Chicago, IL
| | - M Abecassis
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - A Skaro
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - D M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Omran DA, Behairy NHELD, Zakaria KS, Nabil MM, Said K. Functional and morphological myocardial changes in hepatitis C virus patients with end-stage liver disease. Scand J Gastroenterol 2016; 50:1135-43. [PMID: 25716364 DOI: 10.3109/00365521.2015.1019559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Cardiovascular complications are common in liver transplant recipient. This study aims to evaluate functional and morphological myocardial changes in hepatitis C virus (HCV) patients with end-stage liver disease (ESLD) by cardiac magnetic resonance (CMR). METHODS This cross-sectional study included 84 patients with HCV-related ESLD. They were subjected to 2D-echocardiography and CMR. The presence, distribution, and percentage of delayed myocardial enhancement (DME) were estimated. RESULTS The mean Model for End-Stage Liver Disease score was 21.5 ± 6.3. In CMR, all patients showed good global left ventricular (LV) systolic function (mean ejection fraction = 66.5 ± 8.6%; range: 55-80) with normal wall thickness and motion. Left ventricle was mildly dilated in 25 patients (30%). Grade I and grade II diastolic dysfunction was detected in 81 patients (96.4%) with dilated left atrium in 25 patients (30%). Variable degrees of DME were detected in 70 patients (83.3%) with mean percentage of DME (%DME) being 19.5 ± 16% (range: 4-52). A significant negative correlation was found between %DME and LV ejection fraction (r = -0.7; p < 0.001), cardiac output (r = -0.5; p = 0.013), cardiac index (r = -0.5; p = 0.02), and serum albumin level (r = -0.5; p = 0.01). The %DME ≥19% was associated with 85.7% sensitivity and 85.7% specificity for detection of LV ejection fraction <60% as assessed by echocardiography (area under curve = 0.89; p = 0.001). CONCLUSION DME with CMR is a common finding among patients with HCV-related ESLD. The extent of DME is significantly associated with global LV systolic function.
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Affiliation(s)
- Dalia A Omran
- Endemic Medicine Department , Kasr El Ainy Hospital, Cairo University , Cairo , Egypt
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