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Outcomes of Liver Transplantation in Patients With Preexisting Coronary Artery Disease
Emily Reznicek1, Kazunari Sasaki2, Bryce Montane1
1Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH.
Insights
Patients with coronary artery disease (CAD) undergoing liver transplantation face higher mortality risks, particularly from cardiovascular events. Coexisting nonalcoholic steatohepatitis (NASH) further elevates these risks, necessitating aggressive management.
Area of Science:
- Cardiology
- Hepatology
- Transplantation Surgery
Background:
- Liver transplantation technology advances enable procedures for older, higher-risk patients.
- Cardiovascular events are a leading cause of post-transplant mortality despite cardiac testing.
- Limited data exist on liver transplant outcomes for patients with pre-existing coronary artery disease (CAD).
Purpose of the Study:
- To compare all-cause and cardiovascular mortality in liver transplant recipients with and without a history of coronary artery disease (CAD).
Main Methods:
- A retrospective analysis of 693 adult liver transplant recipients between July 2013 and December 2018.
- Comparison of mortality rates between patients with and without pre-existing CAD.
- Follow-up analysis included assessment of cardiovascular events and survival, considering coexisting nonalcoholic steatohepatitis (NASH).
Main Results:
- All-cause mortality was significantly higher in the CAD group (26.7%) compared to the non-CAD group (9.6%).
- Cardiovascular events constituted a larger proportion of deaths in the CAD group (52.5%) versus the non-CAD group (36.5%).
- Patients with combined NASH and CAD showed significantly worse survival at 6 months compared to those with either condition alone.
Conclusions:
- Pre-existing CAD increases the risk of all-cause and cardiovascular mortality after liver transplantation.
- The presence of nonalcoholic steatohepatitis (NASH) exacerbates mortality risk in liver transplant patients with CAD.
- Aggressive risk factor modification is crucial for liver transplant candidates with CAD, especially those with coexisting NASH.
Background:
Advances in surgical and medical technology over the years has made liver transplantation possible for older and higher risk patients. Despite rigorous preoperative cardiac testing, cardiovascular events remain a major cause of death after orthotopic liver transplantation (OLT). However, there are little data on the outcomes of OLT in patients with preexisting coronary artery disease (CAD). This study aimed to compare all-cause and cardiovascular mortality of patients with and without history of CAD undergoing OLT.
Methods:
Six hundred ninety-three adult patients with cirrhosis underwent liver transplantation between July 2013 and December 2018 (female n = 243, male n = 450; median age 59).
Results:
During the study period of 5 y (median follow-up, 24.1 mo), 92 of 693 patients (13.3%) died. All-cause mortality in the CAD group was significantly higher than in the non-CAD group (26.7% versus 9.6%; P <0.01). Cardiovascular events accounted for 52.5% of deaths (n = 21) in patients with CAD compared with 36.5% (n = 19) in non-CAD patients. At 6 mo, patients with combined nonalcoholic steatohepatitis (NASH)/CAD had significantly worse survival than those with CAD or NASH alone ( P <0.01). After 6 mo, patients with CAD alone had similar survival to those with combined NASH/CAD.
Conclusions:
Patients with preexisting CAD before liver transplantation are at higher risk of death from any cause, specifically cardiovascular-related death. This risk increases with coexisting NASH. The presence of NASH and CAD at the time of liver transplant should prompt the initiation of aggressive risk factor modification for patients with CAD.
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