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The Patient with Severe Co-morbidities: Cardiac Disease

  • Shahriar Shayan
  • Andre M. De Wolf
Chapter

Introduction

In order to properly discuss the anesthetic management of patients with cardiac co-morbidities undergoing liver transplantation (LTx), we will first briefly describe the cardiovascular changes that occur as a result of liver failure, including hemodynamic changes and cirrhotic cardiomyopathy. We will then concentrate on the following co-morbidities: coronary artery disease, valvular heart disease, arrhythmias, and hypertrophic obstructive cardiomyopathy. Preoperative diagnosis of cardiac co-morbidities is essential to ensure preoperative optimization and proper intraoperative management and helps to determine the potential need for combined cardiac surgery and LTx. Cardiac complications after liver transplantation is an important cause for postoperative mortality with previous cardiac disease as the main risk factor [1]. Early postoperative death (within 30 days of LTx) is as high as 2.9% and 40% of these mortalities are due to cardiac complications [2]. Poor left...

Keywords

Coronary artery disease Cardiomyopathy Preoperative evaluation Heart failure Myocardial stress test Arrhythmias 

References

  1. 1.
    Fouad TR, Abdel-Razek WM, Burak KW, Bain VG, Lee SS. Prediction of cardiac complications after liver transplantation. Transplantation. 2009;87:763–70.CrossRefPubMedGoogle Scholar
  2. 2.
    VanWagner LB, Lapin B, Levitsky J, Wilkins JT, Abecassis MM, Skaro AI, et al. High early cardiovascular mortality after liver transplantation. Liver Transpl. 2014;20:1306–16.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Shaw BW Jr, Bahnson HT, Hardesty RL, Griffith BP, Starzl TE. Combined transplantation of the heart and liver. Ann Surg. 1985;202:667–72.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Møller S, Henriksen JH. Cardiopulmonary complications in chronic liver disease. World J Gastroenterol. 2006;12:526–38.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Schrier RW, Arroyo V, Bernardi M, Henriksen JH, Rodes J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988;8:1151–7.CrossRefGoogle Scholar
  6. 6.
    Ma Z, Lee SS. Cirrhotic cardiomyopathy: getting to the heart of the matter. Hepatology. 1996;24:451–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Henriksen JH, Møller S. Cardiac and systemic hemodynamic complications of liver cirrhosis. Scand Cardiovasc J. 2009;43:218–25.CrossRefPubMedGoogle Scholar
  8. 8.
    Dowsley TF, Bayne DB, Langnas AN, Dumitru I, Windle JR, Porter TR, et al. Diastolic dysfunction in patients with end-stage liver disease is associated with development of heart failure early after liver transplantation affecting survival. Transplantation. 2012;94:646–51.CrossRefPubMedGoogle Scholar
  9. 9.
    Howell WL, Manion WC. The low incidence of myocardial infarction in patients with portal cirrhosis of the liver: a review of 639 cases of cirrhosis of the liver from 17,731 autopsies. Am Heart J. 1960;60:341–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Kalaitzakis E, Rosengren A, Skommevik T, Björnsson E. Coronary artery disease in patients with liver cirrhosis. Dig Dis Sci. 2010;55:467–75.CrossRefPubMedGoogle Scholar
  11. 11.
    Ehtisham J, Altieri M, Salamé E, Saloux E, Ollivier I, Hamon M. Coronary artery disease in orthotopic liver transplantation: pretransplant assessment and management. Liver Transpl. 2010;16:550–7.PubMedGoogle Scholar
  12. 12.
    Burke A, Lucey MR. Non-alcoholic fatty liver disease, non-alcoholic steatohepatitis and orthotopic liver transplantation. Am J Tranplant. 2004;4:686–93.CrossRefGoogle Scholar
  13. 13.
    Zetterman RK, Belle SH, Hoofnagle JH, Lawlor S, Wei Y, Everhart J, et al. Age and liver transplantation: a report of the Liver Transplantation Database. Transplantation. 1998;66:500–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Kalaitzakis E, Björnsson E. Coronary artery disease in liver cirrhosis: does the aetiology of liver disease matter? J Hepatol. 2009;51:962–3.CrossRefPubMedGoogle Scholar
  15. 15.
    Murray RP, Connett JE, Tyas SL, Bond R, Ekuma O, Silversides CK, et al. Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: is there a U-shaped function? Am J Epidemiol. 2002;155:242–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Berzigotti A, Bonfiglioli A, Muscari A, Bianchi G, LiBassi S, Bernardi M, et al. Reduced prevalence of ischemic events and abnormal supraortic flow patterns in patients with liver cirrhosis. Liver Int. 2005;25:331–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Kadayifci A, Tan V, Ursell PC, Merriman RB, Bass NM. Clinical and pathologic risk factors for atherosclerosis in cirrhosis: a comparison between NASH-related cirrhosis and cirrhosis due to other aetiologies. J Hepatol. 2008;49:595–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Donovan CL, Marcovitz PA, Punch JD, Bach DS, Brown KA, Lucey MR, et al. Two-dimensional and dobutamine stress echocardiography in the preoperative assessment of patients with end-stage liver disease prior to orthotopic liver transplantation. Transplantation. 1996;61:1180–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Plotkin JS, Benitez M, 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.CrossRefPubMedGoogle Scholar
  20. 20.
    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.CrossRefPubMedGoogle Scholar
  21. 21.
    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;27:859–64.CrossRefGoogle Scholar
  22. 22.
    Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y. Morbidity and mortality in patients with coronary artery disease undergoing orthtotopic liver transplantation. Liver Transpl Surg. 1996;2:426–30.CrossRefPubMedGoogle Scholar
  23. 23.
    Diedrich DA, Findlay JY, Harrison BA, Rosen CB. Influence of coronary artery disease on outcomes after liver transplantation. Transplant Proc. 2008;40:3554–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Johnston SD, Morris JK, Cramb R, Gunson BK, Neuberger J. Cardiovascular morbidity and mortality after orthotopic liver transplantation. Transplantation. 2002;73:901–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Wray C, Scovotti JC, Tobis J, Niemann CU, Planinsic R, Walia A, et al. Liver transplantation outcome in patients with angiographically proven coronary artery disease: a multi-institutional study. Am J Transplant. 2013;13:184–91.CrossRefPubMedGoogle Scholar
  26. 26.
    Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2007;50:1707–32.CrossRefPubMedGoogle Scholar
  27. 27.
    Cholongitas E, Senzolo M, Patch D, Shaw S, O’Beirne J, Burroughs AK. Cirrhotics admitted to intensive care unit: the impact of acute renal failure on mortality. Eur J Gastroenterol Hepatol. 2009;21:744–50.CrossRefPubMedGoogle Scholar
  28. 28.
    Lester SJ, Hurst RT. Liver transplantation: do you have the heart for it? Liver Transpl. 2006;12:520–2.CrossRefPubMedGoogle Scholar
  29. 29.
    Sharma M, Yong C, Majure D, Zellner C, Roberts JP, Bass NM, et al. Safety of cardiac catheterization in patients with end-stage liver disease awaiting liver transplantation. Am J Cardiol. 2009;103:742–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Findlay JY, Keegan MT, Pellikka PP, Rosen CB, Plevak DJ. Preoperative dobutamine stress echocardiography, intraoperative events, and intraoperative myocardial injury in liver transplantation. Transplant Proc. 2005;37:2209–13.CrossRefPubMedGoogle Scholar
  31. 31.
    Umphrey LG, Hurst RT, Eleid MF, Lee KS, Reuss CS, Hentz JG, et al. Preoperative dobutamine stress echocardiographic findings and subsequent short-term adverse cardiac events after orthotopic liver transplantation. Liver Transpl. 2008;14:886–92.CrossRefPubMedGoogle Scholar
  32. 32.
    Safadi A, Homsi M, Maskoun W, Lane KA, Singh I, Sawada SG, et al. Perioperative risk predictors of cardiac outcomes in patients undergoing liver transplantation surgery. Circulation. 2009;120:1189–94.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Williams K, Lewis JF, Davis G, Geiser EA. Dobutamine stress echocardiography in patients undergoing liver transplantation evaluation. Transplantation. 2000;69:2354–6.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Harinstein ME, Flaherty JD, Ansari AH, Robin J, Davidson CJ, Rossi JS, et al. Predictive value of dobutamine stress echocardiography for coronary artery disease detection in liver transplant candidates. Am J Transplant. 2008;8:1523–8.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Tsutsui J, Mukherjee S, Elhendy A, Xie F, Lyden ER, O’Leary EO, et al. Value of dobutamine stress myocardial contrast perfusion echocardiography in patients with advanced liver disease. Liver Transpl. 2006;12:592–9.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Abraczinskas DR, Ookubo R, Grace ND, Groszmann RJ, Bosch J, Garcia-Tsao G, et al. Propranolol for the prevention of first esophageal variceal hemorrhage: a lifetime commitment? Hepatology. 2001;34:1096–102.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Berman DS, Abidov A, Kang X, Hayes SW, Friedman JD, Sciammarella MG, et al. Prognostic validation of a 17-segment score derived from a 20-segment score for myocardial perfusion SPECT interpretation. J Nucl Cardiol. 2004;11:414–23.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Kryzhanovski VA, Beller GA. Usefulness of preoperative noninvasive radionuclide testing for detecting coronary artery disease in candidates for liver transplantation. Am J Cardiol. 1997;79:986–8.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Davidson CJ, Gheorghiade M, Flaherty JD, Elliott 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.CrossRefGoogle Scholar
  40. 40.
    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.CrossRefPubMedGoogle Scholar
  41. 41.
    Aydinalp A, Bal U, Atar I, Ertan C, Aktas 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.CrossRefPubMedGoogle Scholar
  42. 42.
    Senzolo M, Bassanello M, Graziotto A, Zucchetta P, Cillo U, Maraglino G, et al. Microvascular autonomic dysfunction may justify false-positive stress myocardial perfusion imaging in patients with liver cirrhosis undergoing liver transplantation. Transplant Proc. 2008;40:1916–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Lanza GA, Crea P. Primary coronary microvascular dysfunction. Clinical presentation, pathophysiology, and management. Circulation. 2010;121:2317–25.CrossRefPubMedGoogle Scholar
  44. 44.
    Guckelberger O, Byram A, Klupp J, Neumann UP, Glanemann M, Stockmann M, et al. Coronary event rates in liver transplant recipients reflect the increased prevalence of cardiovascular risk factors. Transpl Int. 2005;18:967–74.CrossRefPubMedGoogle Scholar
  45. 45.
    Assy N, Djibre A, Farah R, Grosovski M, Marmor A. Presence of coronary plaques in patients with nonalcoholic fatty liver disease. Radiology. 2010;254:393–400.CrossRefPubMedGoogle Scholar
  46. 46.
    McAvoy NC, Kochar N, McKillop G, Newby DE, Hayes PC. Prevalence of coronary artery calcification in patients undergoing assessment for orthotopic liver transplantation. Liver Transpl. 2008;14:1725–31.CrossRefPubMedGoogle Scholar
  47. 47.
    Plotkin JS, Johnson LB, Rustgi V, Kuo PC. CAD and liver transplantation: the state of the art. Liver Transpl. 2000;6:S53–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Warnaar N, Lisman T, Porte RJ. The two tales of coagulation in liver transplantation. Curr Opin Organ Transplant. 2008;13:298–303.CrossRefGoogle Scholar
  49. 49.
    Lisman T, Bongers TN, Adelmeijer J, Janssen HL, de Maat MP, de Groot PG, et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology. 2006;44:53–61.CrossRefGoogle Scholar
  50. 50.
    Kaplan M, Cimen S, Kut MS, Demirtas MM. Cardiac operations for patients with chronic liver disease. Heart Surg Forum. 2002;5:60–5.Google Scholar
  51. 51.
    Hayashida N, Shoujima T, Teshima H, Yokokura Y, Takagi K, Tomoeda H, et al. Clinical outcome after cardiac operations in patients with cirrhosis. Ann Thorac Surg. 2004;77:500–5.CrossRefGoogle Scholar
  52. 52.
    Filsoufi F, Salzberg SP, Rahmanian PB, Schiano TD, Elsiesy H, Squire A, et al. Early and late outcome of cardiac surgery in patients with liver cirrhosis. Liver Transpl. 2007;13:990–5.CrossRefGoogle Scholar
  53. 53.
    Klemperer JD, Ko W, Krieger KH, Connolly M, Rosengart TK, Altorki NK, et al. Cardiac operations in patients with cirrhosis. Ann Thorac Surg. 1998;65:85–7.CrossRefGoogle Scholar
  54. 54.
    An Y, Xiao YB, Zhong QJ. Open-heart surgery in patients with liver cirrhosis. Eur J Cardiothorac Surg. 2007;31:1094–8.CrossRefPubMedGoogle Scholar
  55. 55.
    Bizouarn P, Ausseur A, Desseigne P, Le Teurnier Y, Nougarede B, Train M, et al. Early and late outcome after elective cardiac surgery in patients with cirrhosis. Ann Thorac Surg. 1999;67:1334–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Axelrod D, Koffron A, DeWolf A, Baker A, Fryer J, Baker T, et al. Safety and efficacy of combined orthotopic liver transplantation and coronary artery bypass grafting. Liver Transpl. 2004;10:1386–90.CrossRefPubMedGoogle Scholar
  57. 57.
    Carr C, Desai J. OPCAB surgery in a cirrhotic hepatocellular carcinoma patient awaiting liver transplant. Ann Thorac Surg. 2004;78:1460–2.CrossRefGoogle Scholar
  58. 58.
    Ben Ari A, Elinav E, Elami A, Matot I. Off-pump coronary artery bypass grafting in a patient with Child class C liver cirrhosis awaiting liver transplantation. Br J Anaesth. 2006;97:468–72.CrossRefGoogle Scholar
  59. 59.
    Shaheen AA, Kaplan GG, Hubbard JN, Myers RP. Morbidity and mortality following coronary artery bypass graft surgery in patients with cirrhosis: a population-based study. Liver Int. 2009;29:1141–51.CrossRefPubMedGoogle Scholar
  60. 60.
    Alper I, Ulukaya S, Demir F, Kilic M. Effects of cardiac valve dysfunction on perioperative management of liver transplantation. Transplant Proc. 2009;41:1722–6.CrossRefPubMedGoogle Scholar
  61. 61.
    Pocar M, Passolunghi D, Moneta A, Donatelli F. Primary and redo valve replacement before and after liver transplantation. Eur J Cardiothorac Surg. 2007;32:674–5.CrossRefPubMedGoogle Scholar
  62. 62.
    Iino K, Tomita S, Yamaguchi S, Watanabe G. Successful aortic valve replacement using dilutional ultrafiltration during cardiopulmonary bypass in a patient with Child-Pugh class C cirrhosis. Interact Cardiovasc Thorac Surg. 2008;7:331–2.CrossRefPubMedGoogle Scholar
  63. 63.
    Kalarickal P, Liu Q, Rathor R, Ishag S, Kerr T, Kangrga I. Balloon aortic valvuloplasty as a bridge to liver transplantation in patients with severe aortic stenosis: a case series. Transplant Proc. 2014;46:3492–5.CrossRefPubMedGoogle Scholar
  64. 64.
    Eckhoff DE, Frenette L, Sellers MT, McGuire BM, Contreras JL, Bynon JS, et al. Combined cardiac surgery and liver transplantation. Liver Transpl. 2001;7:60–1.CrossRefPubMedGoogle Scholar
  65. 65.
    Kia L, Shah SJ, Wang E, Sharma D, Selvaraj S, Medina C, et al. Role of pretransplant echocardiographic evaluation in predicting outcomes following liver transplantation. Am J Transplant. 2013;13:2395–401.CrossRefPubMedGoogle Scholar
  66. 66.
    Bargehr J, Trejo-Gutierrez JF, Patel T, Rosser B, Aranda-Michel J, Yataco ML, et al. Preexisting atrial fibrillation and cardiac complications after liver transplantation. Liver Transpl. 2015;21:314–20.CrossRefPubMedGoogle Scholar
  67. 67.
    Van Wagner LB, Serper M, Kang R, Levitsky J, Hohmann S, Abecassis M, et al. Factors associated with major adverse cardiovascular events after liver transplantation among a national sample. Am J Transplant. 2016;16(9):2684–94.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Maron BJ. Hypertrophic cardiomyopathy: a systematic review [review]. JAMA. 2002;287:1308–20.PubMedGoogle Scholar
  69. 69.
    Maraj S, Jacobs LE, Maraj R, Contreras R, Rerkpattanapipat P, Malik TA, et al. Inducible left ventricular outflow tract gradient during dobutamine stress echocardiography: an association with intraoperative hypotension but not a contraindication to liver transplantation. Echocardiography. 2004;21:681–5.CrossRefPubMedGoogle Scholar
  70. 70.
    Rigopoulos AG, Panou F, Kremastinos DT, Seggewiss H. Alcohol septal ablation in hypertrophic obstructive cardiomyopathy [review]. Hell J Cardiol. 2009;50:511–22.Google Scholar
  71. 71.
    Paramesh AS, Fairchild RB, Quinn TM, Leya F, George M, Van Thiel DH. Amelioration of hypertrophic cardiomyopathy using nonsurgical septal ablation in a cirrhotic patient prior to liver transplantation. Liver Transpl. 2005;11:236–8.CrossRefPubMedGoogle Scholar
  72. 72.
    Hage FG, Bravo PE, Zoghbi GJ, Bynon JS, Aqel RA. Hypertrophic obstructive cardiomyopathy in liver transplant patients. Cardiol J. 2008;15:74–9.PubMedGoogle Scholar
  73. 73.
    Lim YC, Doblar DD, Frenette L, Fan PH, Poplawski S, Nanda NC. Intraoperative transesophageal echocardiography in orthotopic liver transplantation in a patient with hypertrophic cardiomyopathy. J Clin Anesth. 1995;7:245–9.CrossRefPubMedGoogle Scholar
  74. 74.
    Harley ID, Jones EF, Liu G, McCall PR, McNicol PL. Orthotopic liver transplantation in two patients with hypertrophic obstructive cardiomyopathy. Br J Anaesth. 1996;77:675–7.CrossRefPubMedGoogle Scholar
  75. 75.
    Cywinski JB, Argalious M, Marks TN, Parker BM. Dynamic left ventricular outflow tract obstruction in an orthotopic liver transplant recipient. Liver Transpl. 2005;11:692–5.CrossRefPubMedGoogle Scholar
  76. 76.
    Chin JH, Kim YK, Choi DK, Shin WJ, Hwang GS. Aggrevation of mitral regurgitation by calcium administration in a patient with hypertrophic cardiomyopathy during liver transplantation: a case report. Transplant Proc. 2009;41:1979–81.CrossRefPubMedPubMedCentralGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Depatment of AnesthesiologyNorthwestern Memorial HospitalChicagoUSA

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