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SPECT myocardial perfusion imaging in liver transplantation candidates

  • Original Article
  • Published:
Journal of Nuclear Cardiology Aims and scope

Abstract

Background

The optimal cardiovascular evaluation prior to liver transplantation remains controversial and includes stress echocardiography, stress MPI, cardiac CTA, and coronary angiography. This study summarizes our experience of the past decade using SPECT MPI in patients with end-stage liver disease, including patient characteristics, stress testing protocols, test results, the need for repeat testing, and downstream testing.

Methods

All patients who underwent a clinically indicated stress SPECT MPI study as part of their pre-liver transplant evaluation from 2004 to 2014 were reviewed from the Nuclear Cardiology database. Results of perfusion imaging, repeat testing, subsequent angiography, and need for revascularization were reviewed.

Results

A total of 2500 patients were referred for SPECT MPI, of those 111 had known CAD and 271 underwent more than one MPI study. Compared to other patients undergoing stress MPI, pre-liver transplant patients were younger, had fewer cardiac risk factors and lower prevalence of prior cardiac history, and used pharmacologic stress more often. During the study decade, patient age increased, prevalence of hypertension increased and smoking decreased, prevalence of known CAD increased, and the number of abnormal studies decreased. Abnormal perfusion results were present in 7.8% of pre-liver transplant patients compared to 34.3% of all other patients. In a multivariate model, age and lower ejection fraction were associated with an abnormal MPI result. Of the 64 patients who underwent subsequent invasive or non-invasive coronary angiography after an abnormal MPI, obstructive CAD was diagnosed in 25 patients (1.0%), non-obstructive CAD was diagnosed in 23 patients (0.9%), and normal coronaries found in 16 patients (0.6%); a total of 18 (0.7%) of these underwent coronary revascularization. The average time to repeat testing was 27.2 ± 17.9 months. In a multivariate model, younger age and exercise stress were associated with repeat testing. In only 17 patients out of 271 with a normal initial perfusion, the repeat study became abnormal. The use of stress-first imaging was successful in 80% of patients with a reduction in Tc-99m dose from 39.1 to 18.3 mCi.

Conclusion

Abnormal SPECT MPI results in candidates for liver transplantation are infrequent compared to non-liver transplant patients and the incidence of obstructive CAD on subsequent angiography even less. Repeat testing in those on the transplant waiting list after initial normal test results appears to be of limited value. Stress-first protocols may be considered for the majority of these patients to reduce testing time and radiation exposure.

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Abbreviations

SPECT:

Single-photon emission computed tomography

MPI:

Myocardial perfusion imaging

CAD:

Coronary artery disease

CTA:

Computed tomography angiography

PCI:

Percutaneous coronary intervention

ESLD:

End-stage liver disease

ETT:

Exercise treadmill testing

OLT:

Orthotopic liver transplantation

CABG:

Coronary artery bypass graft

MI:

Myocardial infarction

References

  1. Transplant trends | UNOS; 2016.

  2. American Liver Foundation—More Information; 2016.

  3. Xia VW, Taniguchi M, Steadman RH. The changing face of patients presenting for liver transplantation. Curr Opin Organ Transplant 2008;13:280-4.

    Article  Google Scholar 

  4. Keeffe BG, Valantine H, Keeffe EB. Detection and treatment of coronary artery disease in liver transplant candidates. Liver Transpl 2001;7:755-61.

    Article  CAS  Google Scholar 

  5. Carey WD, Dumot JA, Pimentel RR, Barnes DS, Hobbs RE, Henderson JM, et al. The prevalence of coronary artery disease in liver transplant candidates over age 50. Transplantation 1995;59:859-64.

    Article  CAS  Google Scholar 

  6. Tiukinhoy-Laing SD, Rossi JS, Bayram M, De Luca L, Gafoor S, Blei A, et al. Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation. Am J Cardiol 2006;98:178-81.

    Article  Google Scholar 

  7. Fili D, Vizzini G, Biondo D, Pietrosi G, Volpes R, Palazzo U, et al. Clinical burden of screening asymptomatic patients for coronary artery disease prior to liver transplantation. Am J Transplant 2009;9:1151-7.

    Article  CAS  Google Scholar 

  8. Ehtisham J, Altieri M, Salame E, Saloux E, Ollivier I, Hamon M. Coronary artery disease in orthotopic liver transplantation: Pretransplant assessment and management. Liver Transpl 2010;16:550-7.

    PubMed  Google Scholar 

  9. Targher G, Day CP, Bonora E. Risk of cardiovascular disease in patients with nonalcoholic fatty liver disease. N Engl J Med 2010;363:1341-50.

    Article  CAS  Google Scholar 

  10. Pruthi J, Medkiff KA, Esrason KT, Donovan JA, Yoshida EM, Erb SR, et al. Analysis of causes of death in liver transplant recipients who survived more than 3 years. Liver Transpl 2001;7:811-5.

    Article  CAS  Google Scholar 

  11. Johnston SD, Morris JK, Cramb R, Gunson BK, Neuberger J. Cardiovascular morbidity and mortality after orthotopic liver transplantation. Transplantation 2002;73:901-6.

    Article  Google Scholar 

  12. Vogt DP, Henderson JM, Carey WD, Barnes D. The long-term survival and causes of death in patients who survive at least 1 year after liver transplantation. Surgery 2002;132:775-80 discussion 80.

    Article  Google Scholar 

  13. de Kroon L, van den Drent G, van den Berg AP, Haagsma EB, Liver Transplant Group G. Current health status of patients who have survived for more than 15 years after liver transplantation. Neth J Med 2007;65:252-8.

    PubMed  Google Scholar 

  14. Fouad TR, Abdel-Razek WM, Burak KW, Bain VG, Lee SS. Prediction of cardiac complications after liver transplantation. Transplantation 2009;87:763-70.

    Article  Google Scholar 

  15. Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: A scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2012;60:434-80.

    Article  Google Scholar 

  16. Martin P, DiMartini A, Feng S, Brown R Jr, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology 2014;59:1144-65.

    Article  Google Scholar 

  17. Zoghbi GJ, Patel AD, Ershadi RE, Heo J, Bynon JS, Iskandrian AE. Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation. Am J Cardiol 2003;92:1066-71.

    Article  Google Scholar 

  18. Bhutani S, Tobis J, Gevorgyan R, Sinha A, Suh W, Honda HM, et al. Accuracy of stress myocardial perfusion imaging to diagnose coronary artery disease in end stage liver disease patients. Am J Cardiol 2013;111:1057-61.

    Article  Google Scholar 

  19. Baker S, Chambers C, McQuillan P, Janicki P, Kadry Z, Bowen D, et al. Myocardial perfusion imaging is an effective screening test for coronary artery disease in liver transplant candidates. Clin Transplant 2015;29:319-26.

    Article  Google Scholar 

  20. Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. J Nucl Cardiol 2016;23:606-39.

    Article  Google Scholar 

  21. Holly TA, Abbott BG, Al-Mallah M, Calnon DA, Cohen MC, DiFilippo FP, et al. Single photon-emission computed tomography. J Nucl Cardiol 2010;17:941-73.

    Article  Google Scholar 

  22. Cousins C, Miller DL, Bernardi G, Rehani MM, Schofield P, Vano E, et al. ICRP PUBLICATION 120: Radiological protection in cardiology. Ann ICRP 2013;42:1-125.

    Article  CAS  Google Scholar 

  23. Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y. Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation. Liver Transpl Surg 1996;2:426-30.

    Article  CAS  Google Scholar 

  24. Therapondos G, Flapan AD, Plevris JN, Hayes PC. Cardiac morbidity and mortality related to orthotopic liver transplantation. Liver Transpl 2004;10:1441-53.

    Article  Google Scholar 

  25. Murray KF, Carithers RL. AASLD. AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology 2005;41:1407-32.

    Article  Google Scholar 

  26. Parikh K, Appis A, Doukky R. Cardiac imaging for the assessment of patients being evaluated for kidney or liver transplantation. J Nucl Cardiol 2015;22:282-96.

    Article  Google Scholar 

  27. Blei AT, Mazhar S, Davidson CJ, Flamm SL, Abecassis M, Gheorghiade M. Hemodynamic evaluation before liver transplantation: Insights into the portal hypertensive syndrome. J Clin Gastroenterol 2007;41(Suppl 3):S323-9.

    Article  Google Scholar 

  28. Kalaitzakis E, Rosengren A, Skommevik T, Björnsson E. Coronary artery disease in patients with liver cirrhosis. Dig Dis Sci 2010;55:467-75.

    Article  Google Scholar 

  29. Plotkin JS, Benitez RM, Kuo PC, Njoku MJ, Ridge LA, Lim JW, et al. Dobutamine stress echocardiography for preoperative cardiac risk stratification in patients undergoing orthotopic liver transplantation. Liver Transpl Surg 1998;4:253-7.

    Article  CAS  Google Scholar 

  30. An J, Shim JH, Kim SO, Lee D, Kim KM, Lim YS, et al. Prevalence and prediction of coronary artery disease in patients with liver cirrhosis: A registry-based matched case-control study. Circulation 2014;130:1353-62.

    Article  Google Scholar 

  31. Ahmadieh H, Azar ST. Liver disease and diabetes: Association, pathophysiology, and management. Diabetes Res Clin Pract 2014;104:53-62.

    Article  CAS  Google Scholar 

  32. Understanding the Organ Transplant Waiting List—Gift of Life Donor Program; 2016.

  33. Hachamovitch R, Hayes S, Friedman JD, Cohen I, Shaw LJ, Germano G, et al. Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans: What is the warranty period of a normal scan? J Am Coll Cardiol 2003;41:1329-40.

    Article  Google Scholar 

  34. Workgroup KD. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005;45:S1-153.

    Google Scholar 

  35. Gaston RS, Danovitch GM, Adams PL, Wynn JJ, Merion RM, Deierhoi MH, et al. The report of a national conference on the wait list for kidney transplantation. Am J Transplant 2003;3:775-85.

    Article  Google Scholar 

  36. Davidson CJ, Gheorghiade M, Flaherty JD, Elliot MD, Reddy SP, Wang NC, et al. Predictive value of stress myocardial perfusion imaging in liver transplant candidates. Am J Cardiol 2002;89:359-60.

    Article  Google Scholar 

  37. Aydinalp A, Bal U, Atar I, Ertan C, Aktaş A, Yildirir A, et al. Value of stress myocardial perfusion scanning in diagnosis of severe coronary artery disease in liver transplantation candidates. Transplant Proc 2009;41:3757-60.

    Article  CAS  Google Scholar 

  38. Bradley SM, Soine LA, Caldwell JH, Goldberg SL. Screening stress myocardial perfusion imaging and eligibility for liver transplantation. Am J Cardiol 2010;105:1010-3.

    Article  Google Scholar 

  39. Torbenson M, Wang J, Nichols L, Jain A, Fung J, Nalesnik MA. Causes of death in autopsied liver transplantation patients. Mod Pathol 1998;11:37-46.

    CAS  PubMed  Google Scholar 

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Disclosure

All funding and support for this work came from within the Division of Cardiology at Mount Sinai and Hartford Hospital. There was no outside funding, grant, or industry support.

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Authors and Affiliations

  1. Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA

    W. Lane Duvall MD & Aditi Singhvi MD

  2. Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA

    Nidhi Tripathi MD

  3. Division of Cardiology, Mount Sinai School of Medicine, New York, NY, USA

    Milena J. Henzlova MD

Authors
  1. W. Lane Duvall MD
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  2. Aditi Singhvi MD
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  3. Nidhi Tripathi MD
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  4. Milena J. Henzlova MD
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Correspondence to W. Lane Duvall MD.

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Duvall, W.L., Singhvi, A., Tripathi, N. et al. SPECT myocardial perfusion imaging in liver transplantation candidates. J. Nucl. Cardiol. 27, 254–265 (2020). https://doi.org/10.1007/s12350-018-1388-3

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  • DOI: https://doi.org/10.1007/s12350-018-1388-3

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