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

Table 1 Transcatheter aortic valve replacement as a bridge to liver transplant: Summary of published cases

Ref.	Case description	Outcome
Silvestre et al[51], 2014	66-year-old male; mean/peak gradient 48/71; MELD 16	No post-TAVR complications; underwent LT 6 months later; no cardiovascular complications at time of LT
Kaafarani et al[53], 2023	63-year-old male; mean/peal gradient: 38.3/67.7; decompensations: Varices, ascites	Post-TAVR stroke like symptoms that self-resolved; successful LT post-TAVR; graft survival > 2 years
Wilkey et al[54], 2016	Severe AS and moderate aortic insufficiency; MELD 29; CTP Class C	Post TAVR complications: Bacteremia and hepato-renal syndrome; still underwent uncomplicated LT one month later
Nemati et al[55], 2008	39-year-old-male with viral hepatitis; decompensations: Severe coagulopathy; CTP Class C	No Post TAVR complications: Successful LT months 2 later
Rejjal et al[56], 2017	56-year-old female; decompensations: Ascites, hepato-renal syndrome; MELD-Na 21	Post-TAVR complications: None; successful LT months 6 later
Kaliamoorthy et al[58], 2020	Patient with bicuspid aortic stenosis; MELD 21	Kiving donors LT 6 months later; no documented complications
Pocar et al[59], 2007	39-year-old male with hydatids liver disease with acute endocarditis; CTP Class C; MELD 26	Post-TAVR complications: Wound infection; successful valve re-replacement following LT
Levy et al[57], 2020	60-year-old male; CTP A, MELD 11; no decompensations	Successful, uncomplicated TAVR; successful LT 6 months later
Levy et al[57], 2020	50-year-old female; CTP B, MELD 19; decompensations: Ascites, hepatic encephalopathy, spontaneous bacterial peritonitis	Successful LT 6 months later

MELD: Model for end stage liver disease; TAVR: Transcatheter aortic valve replacement; LT: Liver transplantation; CTP: Child-Turcotte-Pugh.

Table 2 Scoring systems used in aortic valve replacement

System	Description	Strengths	Limitations
Child-Turcotte Pugh	Developed for surgical risk stratification; assesses risk using five parameters: Ascites, encephalopathy, bilirubin, albumin, and INR	Incorporates clinical factors like ascites and encephalopathy	Subjectivity in grading ascites and encephalopathy
Model for End-Stage Liver Disease	Developed for short-term mortality prediction and organ allocation; calculates score from bilirubin, creatinine, sodium, INR; recently incorporated sex + albumin (3.0)	Objective lab values reduce subjectivity; new version incorporates gender	Does not directly assess cardiac risk; limited predictive accuracy for perioperative outcomes; historic gender vias; several iterations
Model for End-Stage Liver Disease- excluding INR	Modified MELD score that excludes INR	More accurate in predicting 6-month mortality post-TAVR; May not confound bleeding risk with INR	Not routinely used in adult patients
European System for Cardiac Operative Risk Evaluation	Assesses risk of mortality after cardiac surgery based on comorbidities	Widely used for preoperative cardiac risk assessment; considers type of cardiac surgery performed	Does not incorporate liver function; underpredicts mortality in cirrhotic patients
Society of Thoracic Surgeons Risk Score	Assesses risk of mortality after cardiac surgery based on anthropometric profile, comorbidities, medications, labs, and socioeconomic factors	Broader assessment of clinical status; commonly used for valve replacement; includes history of liver disease	May under-estimate risk in cirrhosis; poorly associated with outcomes in patients with cirrhosis in present studies
Veterans Outcomes and Costs Associated with Liver Disease Model	Developed to predict post-operative mortality in patients with cirrhosis, for any surgical procedures	Demonstrated superior discrimination than other surgical risk calculators	Lack of prospective data; data predominantly in men

INR: International normalized ratio; MELD: Model for end stage liver disease; TAVR: Transcatheter aortic valve replacement.