Cardiac Evaluation in Liver Transplant Candidates

Liver transplantation (LT) is the only cure for patients with end-stage liver disease. With an increase in the prevalence of obesity and associated metabolic risk factors cardiovascular disease, in particular coronary artery disease is increasingly recognised in patients with liver cirrhosis. Identification and management of these cardiovascular risk factors may influence post-transplant clinical outcomes. A detailed assessment of patients' cardiovascular status is therefore crucial in the decision-making of patients for LT. Identification of patients with CAD requires risk stratification around perioperative and long term post-operative period. Advanced age, male sex, smoking diabetes mellitus, hypertension, obesity and metabolic-associated steatohepatitis (MASH) cirrhosis significantly increase the risk of coronary artery disease (CAD). Patients with these high-risk factors should undergo cardiac investigations with higher sensitivity to identify CAD. Patients with low-risk factors for CAD may undergo cardiac investigations with high specificity. Patients with cirrhosis may also suffer from conditions directly related to liver disease such as cirrhotic cardiomyopathy and porto-pulmonary hypertension, and conditions unrelated to liver disease such as arrhythmias. Rarely, valvular heart disease may be identified during transplant evaluation. Clinicians managing patients for liver transplantation should carefully evaluate cardiovascular risk and treat it appropriately prior to the surgery, to minimise post-transplant complication. A multidisciplinary approach involving transplant physicians, anaesthetists, cardiologists and transplant surgeons is strongly recommended.