Management of cardiac diseases in liver transplant recipients: Comprehensive review and multidisciplinary practice-based recommendations

Manhal Izzy, Brett E Fortune, Marina Serper, Nicole Bhave, Andrew deLemos, Juan F Gallegos-Orozco, Cesar Guerrero-Miranda, Shelley Hall, Matthew E Harinstein, Maria G Karas, Michael Kriss, Nicholas Lim, Maryse Palardy, Deirdre Sawinski, Emily Schonfeld, Anil Seetharam, Pratima Sharma, Jose Tallaj, Darshana M Dadhania, Lisa B VanWagner, Manhal Izzy, Brett E Fortune, Marina Serper, Nicole Bhave, Andrew deLemos, Juan F Gallegos-Orozco, Cesar Guerrero-Miranda, Shelley Hall, Matthew E Harinstein, Maria G Karas, Michael Kriss, Nicholas Lim, Maryse Palardy, Deirdre Sawinski, Emily Schonfeld, Anil Seetharam, Pratima Sharma, Jose Tallaj, Darshana M Dadhania, Lisa B VanWagner

Abstract

Cardiac diseases are one of the most common causes of morbidity and mortality following liver transplantation (LT). Prior studies have shown that cardiac diseases affect close to one-third of liver transplant recipients (LTRs) long term and that their incidence has been on the rise. This rise is expected to continue as more patients with advanced age and/or non-alcoholic steatohepatitis undergo LT. In view of the increasing disease burden, a multidisciplinary initiative was developed to critically review the existing literature (between January 1, 1990 and March 17, 2021) surrounding epidemiology, risk assessment, and risk mitigation of coronary heart disease, arrhythmia, heart failure, and valvular heart disease and formulate practice-based recommendations accordingly. In this review, the expert panel emphasizes the importance of optimizing management of metabolic syndrome and its components in LTRs and highlights the cardioprotective potential for the newer diabetes medications (e.g., sodium glucose transporter-2 inhibitors) in this high-risk population. Tailoring the multidisciplinary management of cardiac diseases in LTRs to the cardiometabolic risk profile of the individual patient is critical. The review also outlines numerous knowledge gaps to pave the road for future research in this sphere with the ultimate goal of improving clinical outcomes.

Keywords: cardiac outcomes; cirrhotic cardiomyopathy; coronary artery disease; liver transplant.

Conflict of interest statement

Disclosure:

B.E.F. is a consultant for W.L. Gore & Associates and Cook Medical.

L.B.V. receives investigator-initiated grant support from W.L. Gore & Associates, grant support from Intercept Pharmaceuticals, and grant support from AMRA Medical outside the scope of this work. All other authors declare no conflicts of interest.

Darshana M. Dadhania and Lisa B. VanWagner contributed equally.© 2022 The American Society of Transplantation and the American Society of Transplant Surgeons.

Figures

Figure 1.
Figure 1.
Established Risk factors for Coronary Heart Disease among Liver Transplant Recipients This figure demonstrates transplant recipient-specific, donor-specific, and general risk factors for coronary heart disease CHD, coronary heart disease; BMI, body mass index; NASH, non-alcoholic steatohepatitis; CNI, calcineurin inhibitor; CSA, cyclosporine; Tac, tacrolimus; MELD, model for end stage liver disease; ICU, intensive care unit; RBC, red blood cell; LDL, low density lipoprotein; CACS, coronary artery calcium score
Figure 2.
Figure 2.
The revised criteria for cirrhotic cardiomyopathy This figure highlights the components of comprehensive echocardiographic evaluation of systolic function and diastolic function. In the case of liver transplant candidates, systolic or diastolic dysfunction in the absence of known cardiac pathology (e.g., coronary artery disease) is diagnostic of cirrhotic cardiomyopathy. * One criterion is needed to make the diagnosis of systolic dysfunction. ** The presence of 3 criteria indicates the presence of advanced diastolic dysfunction that can be graded based on E/A ratio but the presence of 2 criteria requires further testing to determine the degree of diastolic dysfunction.
Figure 3.
Figure 3.
The elements of multidisciplinary care for liver transplant recipients with established cardiac disease This figure summarizes the necessary measures that should be followed to optimize outcomes in liver transplant recipients with cardiac disease. These measures surround metabolic syndrome, chronic kidney disease, and surveillance of cardiac disease.

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Source: PubMed

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