Aortic stenosis in cirrhosis: Pathophysiology and management in the context of liver transplantation

Abstract

Aortic stenosis (AS), a progressive disease affecting aortic valve function, is common among individuals with metabolic and degenerative conditions, and is notably challenging to manage in patients with cirrhosis. Patients with cirrhosis frequently experience exacerbated AS symptoms due to the hyperdynamic circulatory state induced by portal hypertension, which masks early AS signs, resulting in delayed diagnosis. The coexistence of AS and liver disease significantly complicates management, particularly for those awaiting liver transplantation (LT), where untreated AS can increase perioperative morbidity and mortality. This review examines the pathophysiology, clinical manifestations, and management of AS in cirrhotic patients, with a focus on implications for LT candidates. Available treatment options, including surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR), are discussed, with TAVR emerging as a preferred approach due to favorable outcomes in high-risk patients. We also explore the potential role of TAVR as a bridge to LT, with case reports showing promising, albeit anecdotal, success in restoring LT candidacy. Limitations in current perioperative risk assessment tools, which inadequately address the unique risks faced by cirrhotic patients undergoing cardiac procedures, highlight the need for multi-disciplinary care and further research to improve outcomes of patients with concomitant end-stage liver disease and AS.

Keywords: Aortic stenosis; Liver transplant; Cardio-hepatology; End stage liver disease; Aortic valve replacement

Core Tip: Managing aortic stenosis in patients with cirrhosis presents unique challenges due to overlapping pathophysiology and high surgical risks, particularly for those undergoing liver transplantation. Transcatheter aortic valve replacement is emerging as the preferred intervention for high-risk cirrhotic patients, offering improved short-term outcomes and the potential to serve as a bridge to liver transplantation. Current perioperative risk scoring systems inadequately account for liver disease, highlighting the need for specialized guidelines and a multidisciplinary approach to optimize outcomes in this complex patient population.