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Introduction of a standardized protocol for cardiac risk assessment in candidates for liver transplant - A
Killian J McCarthy1, Daniel Motta-Calderon2, Alisson Estrada-Roman3
1Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA, United States.
Insights
Implementing a new protocol for assessing cardiac risk in liver transplant candidates led to increased use of coronary computed tomography angiography (CCTA) and higher obstructive coronary artery disease (CAD) diagnoses, without impacting post-transplant cardiac complications.
Area of Science:
- Cardiology
- Transplant Surgery
- Medical Imaging
Background:
- Liver transplant candidate cardiac risk assessment guidelines vary.
- Standardized pre-transplant coronary evaluation protocols are needed for consistency.
- Beth Israel Deaconess Medical Center implemented a protocol in 2018.
Purpose of the Study:
- To evaluate the impact of a standardized pre-transplant coronary evaluation protocol.
- To assess changes in non-invasive versus invasive cardiac testing methods.
- To determine the effect of the protocol on post-transplant cardiac complications.
Main Methods:
- Retrospective analysis of 462 liver transplant candidates (2016-2019).
- Categorization into three cohorts: pre-protocol, initial protocol (coronary angiography), and amended protocol (CCTA).
- Univariate analysis using Cochran-Armitage Exact Trend Test.
Main Results:
- Coronary computed tomography angiography (CCTA) use increased significantly across cohorts (3% to 26.3%).
- Obstructive coronary artery disease (CAD) diagnosis via CCTA rose significantly (0% to 51.4%).
- No significant difference in post-transplant cardiac complications observed between cohorts.
Conclusions:
- A shift towards less invasive imaging like CCTA is reasonable for at-risk liver transplant candidates.
- The protocol facilitated a move towards non-invasive cardiac risk assessment.
- Standardized protocols can guide appropriate pre-operative cardiac evaluation.
Introduction:
Recommendations on non-invasive imaging to assess pre-operative cardiac risk among liver transplant candidates vary amongst societal guidelines and individual institutional practices. In 2018, a standardized pre-transplant coronary evaluation protocol was established at Beth Israel Deaconess Medical Center, Boston MA, to ensure appropriate and consistent pre-operative testing was performed.
Methods:
All patients who underwent liver transplant evaluation between January 1st, 2016 and December 31st, 2019, were retrospectively analyzed and divided into three cohorts; before the introduction of the protocol (prior to 2018), initial protocol favoring invasive coronary angiography (ICA) (2018), and amended protocol favoring coronary computed tomography angiography (CCTA) (post-2018). We described clinical characteristics, candidacy for transplant, and cardiovascular complications during follow-up. As an unadjusted exploratory analysis, the Cochran-Armitage Exact Trend Test was used to examine univariate differences across time.
Results:
A total of 462 patients underwent liver transplant evaluation during the study period. Among these, 218 (47.2%) patients underwent stress test, 50 (10.8%) underwent CCTA, and 68 (14.8%) underwent ICA. Across the three time periods, there was an increase in the proportion of CCTAs performed (3%, 6.3%, and 26.3% respectively; p <0.001) and proportion of patients diagnosed with obstructive CAD using CCTA (0%, 30%, and 51.4% respectively; p = 0.04). There was no significant difference in post-transplant cardiac complications among patients evaluated before 2018, during 2018, and after 2018 (5.9% vs. 5.6 vs. 6.0%; p=1.0).
Conclusion:
Our findings suggest it is reasonable to shift practice to a less invasive approach utilizing CCTA or nuclear stress testing when assessing liver transplant candidates at increased cardiovascular risk.
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