Cardiac risk stratification of the liver transplant candidate: A comprehensive review

Table 1 Preoperative assessment of common cardiac diseases and relationship with liver transplant outcomes

	Pretransplant	During transplant	Post-transplant
Coronary artery disease	Prevalence 2%-38%. Screening: DSE (high NPV), SPECT myocardial perfusion, conventional coronary angiography (gold standard)		Cumulative 3-yr post-LT MACE incidence: 37.5%. All-cause mortality: 13%
Cirrhotic cardiomyopathy	Prevalence 40%-50%. TTE is the preferred method for the diagnosis of systolic or diastolic dysfunction preoperatively	23% abnormal cardiac response	Pretransplant diastolic dysfunction increase the risk for acute graft rejection or failure, and all-cause mortality
Valvular heart disease	27.5% with cardiac valve dysfunction. Routine TTE screening is recommended prior to LT	Severe aortic stenosis associated with 31% risk of perioperative complications	Pretransplant AV replacement or AS increase the likelihood for significant cardiac complications 1-3 yr post-LT
Portopulmonary hypertension	Prevalence 5%-8.5%. Preoperative screening with TTE is recommended to all LT candidates. Patients with RVSP > 45 mm Hg needs confirmation with RHC	MPAP > 50 mm Hg: 100% mortality. MPAP 35-50 mm Hg: Increased morbidity and mortality. MPAP < 35 mm Hg and MPAP > 35 mm Hg due to volume overload or hyperdynamic state: No increase in mortality
Conduction abnormalities	Routine ECG should be performed in all LT candidates independently of a cardiac abnormality history		AF is the most common MACE in the first 90 d post-transplant (-43%). AF is an independent risk factor for MACE 30- and 90-d after LT
QTc prolongation	Common ECG finding in ESLD patients with CCM; no sex-based differences exist as in general population. Reversible causes of QTc prolongation should be identified and corrected preoperatively		Conflicting data exist regarding QTc prolongation as an independent predictor of mortality and its reversibility post-LT

LT: Liver transplantation; DSE: Dobutamine stress echocardiogram; NPV: Negative predictive value; SPECT: Single-photon emission computerized tomography; MACE: Major adverse cardiac events; TTE: Transthoracic echocardiogram; AV: Aortic valve; AS: Aortic stenosis; RVSP: Right ventricular systolic pressure; RHC: Right heart catheterization; MPAP: Mean pulmonary arterial pressure; ECG: Electrocardiogram; AF: Atrial fibrillation; ESLD: End-stage liver disease; CCM: Cirrhotic cardiomyopathy; QTc: Corrected QT.