Impact of Preoperative Cardiac Screening Modality on Cardiovascular Outcomes After Liver Transplantation

Cardiovascular (CV) disease is a leading cause of morbidity and mortality after liver transplantation (LT). Coronary computed tomography angiography (CCTA) has increasingly replaced stress testing (ST) for CV risk assessment in LT candidates with intermediate-to-high CV risk, although comparative evidence remains limited. The primary endpoint was the incidence of post-LT major adverse cardiovascular events (MACE) by CV screening modality; the secondary endpoint was to identify predictors of MACE.

This single-center retrospective study included 506 patients who underwent LT between 2018 and 2023. According to CV screening modality, patients were stratified into three groups: no test (low CV risk), ST, or CCTA.

Among 506 LT recipients, 358 (70.8%) presented low CV risk, 57 (11.3%) underwent ST, and 91 (18.0%) CCTA. Compared with ST, CCTA led to higher rates of coronary angiography (14% vs. 31.9%, p = 0.011) and revascularization (0% vs. 15.4%, p < 0.0001). After a median follow-up of 2.5 years [IQR 1.5-3.9], MACE occurred more frequently in CCTA (18.4%) and ST (14%) groups than in low-risk group (9%) (p = 0.041), while no significant difference was observed between CCTA and ST groups (14% vs. 18.4%, p = 0.501). In univariate and multivariate Cox-regression analysis, only age and family history of coronary artery disease were independent predictors of MACE.

CCTA and ST resulted in comparable post-LT CV outcomes. Although CCTA was associated with a higher number of pre-LT coronary interventions, it was not associated with a lower incidence of MACE, underscoring the need to refine CV risk stratification protocols in LT candidates.

Currently, there are no international guidelines for cardiovascular screening procedures in LT candidates, leading to variability in practice across different centers and countries. Coronary computed tomography angiography (CCTA) has emerged as a more accurate method than stress testing (ST) in detecting coronary artery disease (CAD) in patients with end-stage liver disease. In the present study, all pre-transplant coronary revascularizations were performed in patients screened with CCTA, while none occurred in the ST group. Despite this, the incidence of post-LT major adverse cardiovascular events (MACE) was similar between groups. In our cohort, revascularizations prompted by CCTA did not significantly reduce post-LT MACE rate. Age and family history of CAD were the only independent predictors of MACE. Our results underscore the need to refine cardiovascular risk stratification protocols for LT candidates.