The cardiac evaluation of liver transplant recipients: a single center's experience

Orthotopic liver transplantation is both a difficult and a demanding surgical procedure. It is not unexpected that cardiovascular dysfunction is present in some individuals being evaluated for liver transplantation. Thus, all potential liver transplant recipients seen at this center undergo a full cardiac evaluation prior to being accepted for transplantation. The goal of this report was to review the components of the cardiovascular evaluation utilized at the Oklahoma Transplantation Institute and to determine their overall usefulness as well as the ability of the process to identify individuals at high risk for a cardiac misadventure during liver transplantation.

Between June 25, 1993 and June 30, 1995, a total of 154 consecutive patients with chronic liver disease were evaluated. The primary liver disease of each was established utilizing specific serologic and biochemical tests, ultrasonographic and abdominal tomographic findings, as well as hepatic histology results and hepatic iron and copper level determinations. Each liver transplant candidate underwent a full cardiac evaluation consisting of the following: nuclear ventriculography to estimate the left ventricular ejection fraction (at rest and during exercise), right ventricular ejection fraction, cardiac output, stroke volume and cardiac index; uptake images using thallium and adenosine to identify foci of cardiac ischemic or fixed defects; echocardiography to define the dimensions of the various cardiac chambers, wall thicknesses, cardiac contractility and morphology of the cardiac valves. Finally, coronary arteriography was performed in 26 patients (16.9%) who were suspected of having clinically important coronary artery disease. It should be noted that all of the cardiac evaluations were performed by a single cardiologist.

Eight of the 154 potential liver transplant candidates (5.2%) were determined as not being eligible for liver transplantation because of an inadequate cardiac status based upon an initial history and physical examination. Forty-one of the remaining 146 patients (28.1%) underwent liver transplantation. The remaining 105 subjects have not been transplanted for reasons not related to the cardiac status. Eight of the 41 (19.5%) transplanted patients had a clinically advanced cardiac problem recognized prior to liver transplantation. Four of these eight required a specific cardiac intervention prior to liver transplantation consisting of coronary bypass surgery (n = 1), coronary artery balloon dilation (n = 2) or pericardiectomy (n = 1). The remaining four patients required no pretransplant cardiac intervention and were transplanted. None of these experienced any cardiac complications during, or in the 3 months following, the liver transplant procedure. Only one patient experienced a specific postoperative cardiac complication, consisting of an episode of high grave A-V block requiring transplant placement of a cardiac pacing device. This patient had hemochromatosis.

Based upon this experience, it can be concluded that coronary artery disease per se is not an absolute contraindication for liver transplantation. With appropriate treatment, liver transplantation can be performed safely in individuals with confounding cardiac disease. Nuclear ventriculography and echocardiography are essential procedures in evaluating potential liver transplant recipients in an effort to exclude those with occult cardiomyopathy. Coronary arteriography is indicated only in selected cases with evidence of cardiac ischemia or infarction.