The safety of cardiac operations in the liver transplant recipient

Advances in surgical techniques and immunosuppressive drugs have improved the survival of patients after orthotopic liver transplantation. Enhanced survival has resulted in an increased number of patients who require medical as well as surgical management of diseases.

To contribute to the sparse literature on the surgical aspects, we reviewed our experience with 15 patients who underwent cardiac operation (1.25%) from a total of 1,200 liver transplant recipients at our center. The variables studied included the pretransplant cardiac evaluation, the interval from transplantation to cardiac operation, postoperative complications, the management of immunosuppression, and follow-up. The patients had a mean age of 52.9 years (range, 39 to 69 years) and 13 of them (86.6%) were men. Multiple cardiac risk factors were present in all 15 patients and chronic renal insufficiency was present in 7 patients. Cardiac operation was undertaken a mean of 30.4 months (range, 9 days to 62 months) after myocardial ischemia and valvular regurgitation had been ruled out at the time of transplantation. Myocardial revascularization was performed in 12 patients, 2 of whom underwent concurrent valve operation and 3 of whom underwent valve repair or replacement. Most patients had their immunosuppression regimen continued at baseline levels.

There were no early deaths. Three patients had major complications and 4 had minor complications. There were no bleeding, infection, or healing complications. Postoperative renal parameters were persistently elevated in 5 patients and transiently elevated in 3. Liver function parameters were transiently elevated in 6 patients after the cardiac operation. No patient had hepatic rejection. A transient elevation or decrease in immunosuppressive drug levels was seen in 3 patients. Follow-up, obtained on all 15 patients, ranged from 6 to 83 months (mean, 26.5 months). There were 2 late deaths (13.3%), and 3 patients (25%) who underwent myocardial revascularization had recurrent angina.

Cardiac operations can be undertaken safely in liver transplant recipients with good intermediate-term results. The immunosuppression regimen can be continued at preoperative levels with no need for stress-dose steroids. There were no hepatic complications among our patients, although some patients can experience worsening of renal failure.