Induced myocardial ischemia in candidates to liver transplantation without evidence of heart disease

Abstract

Background: Coronary artery disease (CAD) is associated with perioperative liver transplantation (LT) mortality. In absence of a defined risk algorithm, we aimed to test whether stress echocardiography and coronary computed tomography angiography (CCTA) could detect CAD in end-stage liver disease (ESLD) patients without previous evidence of heart disease.

Methods: LT candidates ≥30 years underwent a cardiovascular (CV) assessment through stress echocardiography. CCTA was performed in patients ≥50 years with two or more CV risk factors (e.g. diabetes, CAD family history, dyslipidaemia). Coronary angiography (CAG) was scheduled when stress echocardiography and/or CCTA were positive. Sensibility, specificity, positive and negative predictive values of stress echocardiography and CCTA were assessed by numbers of coronary revascularization (true positives) and lack of acute coronary events over a mean follow-up of 3 years (true negatives).

Results: Stress echocardiography was performed in 273 patients, CCTA in 34 and CAG in 41. Eight patients had critical coronary lesions, and 19 not-critical lesions. Sensitivity, specificity, positive and negative predictive values were 50.0%, 90.2%, 13.3% and 98.4% for stress echocardiography and 100%, 76.7%, 36.4% and 100% for CCTA. Among 163 patients who underwent LT (57.6%), 16 died and 5 had major adverse CV events over a mean follow-up of 3 years.

Conclusions: A very low prevalence of CAD in a selected population of ESLD at intermediate to high CV risk was found. A screening based on stress echocardiography and CCTA resulted in low incidence of post-LT acute coronary events in ELSD patients. CAD has no impact on mid-term survival.

Keywords: Coronary artery disease; computed tomography angiography; end-stage liver disease.

Figure 1.

Protocol to assess preoperatory cardiological risk in patients underwent liver transplantation. The number of patients allocated to single tests has been reported in brackets. CAD: coronary artery disease; CAG: coronary angiography; CCTA: coronary computed tomography angiography; CV-RF: cardiovascular risk factors; DM: diabetes mellitus; ECG: electrocardiogram; LT: liver transplantation; PCI: percutaneous coronary intervention; SE: stress echocardiography.

Figure 2.

Kaplan–Meier’s curves relative to event-free survival in patients underwent liver transplantation. Patients were divided among the four CAG-related groups as follows: NO CAG: patients not subjected to coronary angiographies; CAG – NEG: negative coronary angiographies; CAG – NCC: non-critical coronaropathy; CAG – PCI: critical coronaropathy requiring revascularization. Censored patients are detailed by markings on the respective curves.