Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation (original) (raw)
Related papers
Coronary artery disease and liver transplantation: The state of the art
Liver Transplantation, 2000
he idea that liver disease is somehow protective T from atherosclerotic coronary artery disease (CAD) has been repeatedly shown not to be valid. In addition, the cardiovascular demands of end-stage liver disease, as well as the orthotopic liver transplantation (OLT) procedure itself, are such that a hindrance to myocardial oxygen supply may be disastrous. This article attempts to summarize the state-of-the-art knowledge about the incidence and preoperative detection of CAD in the OLT population, as well as the results of Addrrss rrprint reqursts to Jr& S. Plotkin. MD, Arsoriatr Profism of Anrrtbrsiology and Surgrty, [Xrrrror 7kansplani Anrstbcsioh~ and Critical Carr, Grotgrtown Transplant Inrritutr. Groqrtouq Ilnirirrrq Mrdiral Ccntrr. .MOO Rrsrnmir M, NW. 4 PtfC Hldg, Wahingron. DC 20007. Tdrphonr: 202-784-3700; FAX: 202-6(17:3004; E-marl: plotkrnj@gunrt.grotgttown.rdu Copyright (0 2 0 0 by thr Amrriran As~oc~arron fir thr . S d y of Livrr Disrasrs
Liver Transplantation, 2010
The prevalence of coronary artery disease in end-stage liver disease is only now being recognized. Liver transplant patients are a high risk subgroup for coronary artery disease, even if asymptomatic. Coronary artery disease is a predictor of poor outcomes; therefore, identification of those at risk must be a key clinical priority. However, risk assessment is particularly difficult as many of the available diagnostic tools have either proven to be unhelpful or remain to be validated. Risk factor profiling has been unable to identify those at risk and commonly underestimates risk. The high negative predictive value of Dobutamine stress echo, when target heart rates are achieved, allows it to be used to identify a low risk group. For all other patients, proceeding to invasive coronary angiography is often necessary, and the risks of the procedure can be reduced by a transradial approach. Pharmacological reduction of the consequences of coronary artery disease can be limited by the underlying liver disease. Revascularization pre-transplantation is recommended in international guidelines but has demonstrated little evidence of benefit. Surgical revascularization carries an increased risk in these patients and is commonly performed pre-transplantation, although combined liver and cardiac surgery has been described. Percutaneous coronary intervention is increasingly used with patients requiring anti-platelet medication for up to one year after intervention. We present a review of all these issues and the evidence for assessing and managing these high-risk patients. Liver Transpl 16:550-557,
Safety and efficacy of combined orthotopic liver transplantation and coronary artery bypass grafting
Liver Transplantation, 2004
Advanced coronary artery disease (CAD) is increasingly common in patients awaiting orthotopic liver transplantation (OLT). Unfortunately, in patients whose coronary artery anatomy is not amenable to angioplasty, coronary artery bypass grafting (CABG) alone may precipitate hepatic decompensation. Thus, combined liver transplant and coronary artery bypass grafting (CABG-OLT) may be required to effectively treat both conditions. Clinical records were analyzed for 5 CABG-OLT procedures at a single institution. Operative indications, technical details, and postoperative course were determined for each patient. Patients undergoing CABG-OLT had a mean age of 57.8 years (range, 54-66) and were predominantly male (80%). All patients had significant 3-vessel coronary atherosclerotic disease with preserved left ventricular function. There were no intraoperative deaths. At mean 25 months of follow-up (range, 8.0-25) there was an 80% graft and patient survival. Overall average length of stay was 21 days (range, 7-59 days). In conclusion, CABG-OLT procedure appears to be safe and effective in the population of patients with advanced CAD and liver disease. In this series, patients appear to benefit from multidisciplinary preoperative evaluation, coordination between cardiac and transplant surgeons, careful graft selection, and use of sapheno-atrial veno-veno bypass.
Clinical Transplantation, 1999
TJ. Is the presence of surgically treatable coronary artery disease a contraindication to liver transplant? Clin Transplantation 1999: 13: 59 -61 . © Munksgaard, 1999 Abstract: Advanced coronary artery disease has been traditionally considered an absolute contraindication to orthotopic liver transplantation where chronic liver failure significantly increases the surgical risk for coronary artery bypass grafting. Performing a simultaneous coronary artery bypass grafting and liver transplant is a theoretically attractive strategy in liver transplant candidates with coronary artery disease in need of revascularization. In the present article, we report a successful simultaneous coronary artery bypass grafting and orthotopic liver transplant with 1-yr post-operative follow-up and we discuss the rationale for this approach. In selected cases, the presence of advanced coronary artery disease should not be considered an absolute contraindication to liver transplantation.
Liver Transplantation, 2010
The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P ¼ 0.046), increased length of stay (22 versus 15 days, P ¼ 0.050), and postoperative pressor requirements (27% versus 4%, P ¼ 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup.
Combined Coronary Bypass and Liver Transplantation: Technical Considerations
The Annals of Thoracic Surgery, 1998
Kawasaki coronary artery disease. J Thorac Cardiovasc Surg 1994;107: 663-74. 2. Kitamura S, Seki T, Kawachi K, et al. Excellent patency and growth potential of internal mammary artery grafts in pediatric coronary bypass surgery: new evidence for a "live" conduit. Circulation 1989;78(Suppl 1):29-39.
Indian Journal of Anaesthesia, 2013
A 62-year-old man (156 cm, 48 kg), scheduled to undergo LRLT for cryptogenic ESLD (Child-Turcotte-Pugh score 9, MELD 12), was decompensated with hepatic encephalopathy, ascites and hepatorenal syndrome. He also had hypertension and diabetes mellitus. He suffered cardiac arrest lasting approximately 30 seconds during large volume paracentesis 8 months ago. A quicker decompression probably induced asystole. Post-cardiac arrest, there was no neurological deficit. He had effort tolerance of NYHA class II. Preoperative echocardiogram showed ejection fraction (EF) of 55% with no pulmonary hypertension. Dobutamine stress echocardiogram was negative for inducible ischemia. Preoperative angiography revealed 30% block in proximal left-anterior descending
Transplantation, 2017
Coronary artery disease (CAD) is a significant problem during evaluation for liver transplantation (LT). We aim to assess survival in LT recipients based on presence, severity, extent of CAD and cardiac events within 90 days of LT. 87 LT recipients with history of pre-LT angiogram (12/2005-12/2012) were compared with 2 control groups without prior angiogram, 72 LT recipients matched for cardiovascular risk factors (Control Gr I), and 119 consecutive LT recipients without any CV risk factors (Control Gr II). CAD was assessed by (1) vessel score (≥ 50% reduction in luminal diameter), and (2) Extent score (Reardon scoring system). Of the 87 LT recipients (study group), 58 (66.7%) had none or < 50% stenosis, 29 (33.3%) had obstructive CAD (≥50% stenosis), 7(8%) with single vessel disease, and 22 (25.3%) with multi-vessel disease. In the study group, irrespective of prerevascularization severity of CAD (P=0.357), number of segments involved (0, 1-2, > 2 segments, P=0.304) and exten...
Liver Transplantation, 2010
The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P = 0.046), increased length of stay (22 versus 15 days, P = 0.050), and postoperative pressor requirements (27% versus 4%, P = 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup. Liver Transpl 16:1242-1248, 2010. © 2010 AASLD.
Simultaneous coronary artery bypass grafting and orthotopic liver transplantation
Transplant International, 2003
The study presents a case of a 66-year old male patient with coronary heart disease and a history of inferior wall myocardial infarction. During hospitalization the patient suddenly demonstrated symptoms of obstructive jaundice. The increasing intensity of these symptoms augmented the pre-existent coronary insufficiency, which was classified as stage 3 on the CCS scale. We encountered some circumstances, which rendered use of minimally invasive procedures impossible. Therefore, the patient was treated with combined therapy involving coronary artery bypass grafting on a beating heart, and evacuation of biliary stones followed by drainage of the biliary tract with the use of the T-drain (Kehr's method).