Appraising Cardiac Dysfunction in Liver Transplantation
Appraising Cardiac Dysfunction in Liver Transplantation
End-stage liver disease (ESLD) is a multisystemic disease that adversely and mutually aggravates other organs such as the heart. Cardiac dysfunction in ESLD encompasses a spectrum of disease that could be aggravated, precipitated or be occurring hand-in-hand with coexisting aetiological factors precipitating cirrhosis. Additionally and more complexly, liver transplantation, the curative modality of ESLD, is responsible for additional intra- and postoperative short- and long-term cardiac morbidity. The phenotypic distinction of the different forms of cardiac dysfunction in ESLD albeit important prognostically and therapeutically is not allowed by the current societal recommendations, due to conceptual, and methodological limitations in the appraisal of cardiac function and structure in ESLD and in designing studies that are based on this appraisal. This review comprehensively discusses the spectrum of cardiac dysfunction in ESLD, discusses the limitations of the current appraisal of cardiac dysfunction in ESLD, and proposes a hypothetical approach for studying cardiac dysfunction in liver transplant candidates.
End-stage liver disease (ESLD) is a multisystem disease that complexly and mutually interacts with other body organs. The heart is one of the organs most adversely affected by liver disease both directly and indirectly. Cardiac dysfunction in the setting of cirrhosis may contribute to mortality as high as 50% post-liver transplantation. The spectrum of heart diseases associated with cirrhosis includes three major groups:
Liver transplantation while considered the definitive treatment of patients with ESLD, can independently contribute to further deterioration of pre-existing cirrhosis-associated cardiac dysfunction. These adverse effects occur as a result of acute changes in loading conditions, and the liberation of inflammatory cytokines and other mediators during graft reperfusion. Furthermore, following liver transplantation, there is an increased risk of adverse cardiac events associated with chronic immunosuppressive therapy. Thus, patients such as these warrant a thorough cardiac evaluation prior to being deemed acceptable liver transplant candidates.
A thorough cardiac evaluation of liver transplant candidates is a challenging task, however. Altered cardiac response to stress, heterogeneity and progression of cardiac disease in liver transplant candidates, and the paucity of well-designed studies investigating pre-operative cardiac testing; all explain the current lack of agreement on a single best screening strategy to optimize perioperative outcomes.
This review will discuss the following: profiles of cardiac dysfunction in ESLD, short- and long-term cardiac dysfunction associated with liver transplantation, and the pre-operative evaluation of liver transplant candidates in the light of the current evidence, appraising its limitations. Also, this review will propose avenues for future investigation of cardiac function in liver transplant candidates.
Abstract and Introduction
Abstract
End-stage liver disease (ESLD) is a multisystemic disease that adversely and mutually aggravates other organs such as the heart. Cardiac dysfunction in ESLD encompasses a spectrum of disease that could be aggravated, precipitated or be occurring hand-in-hand with coexisting aetiological factors precipitating cirrhosis. Additionally and more complexly, liver transplantation, the curative modality of ESLD, is responsible for additional intra- and postoperative short- and long-term cardiac morbidity. The phenotypic distinction of the different forms of cardiac dysfunction in ESLD albeit important prognostically and therapeutically is not allowed by the current societal recommendations, due to conceptual, and methodological limitations in the appraisal of cardiac function and structure in ESLD and in designing studies that are based on this appraisal. This review comprehensively discusses the spectrum of cardiac dysfunction in ESLD, discusses the limitations of the current appraisal of cardiac dysfunction in ESLD, and proposes a hypothetical approach for studying cardiac dysfunction in liver transplant candidates.
Introduction
End-stage liver disease (ESLD) is a multisystem disease that complexly and mutually interacts with other body organs. The heart is one of the organs most adversely affected by liver disease both directly and indirectly. Cardiac dysfunction in the setting of cirrhosis may contribute to mortality as high as 50% post-liver transplantation. The spectrum of heart diseases associated with cirrhosis includes three major groups:
Heart disease aggravated by cirrhosis
Disease that is caused by a pathological process that concomitantly affects the heart and the liver
Cardiac disease (vascular, myocardial or pericardial)
Liver transplantation while considered the definitive treatment of patients with ESLD, can independently contribute to further deterioration of pre-existing cirrhosis-associated cardiac dysfunction. These adverse effects occur as a result of acute changes in loading conditions, and the liberation of inflammatory cytokines and other mediators during graft reperfusion. Furthermore, following liver transplantation, there is an increased risk of adverse cardiac events associated with chronic immunosuppressive therapy. Thus, patients such as these warrant a thorough cardiac evaluation prior to being deemed acceptable liver transplant candidates.
A thorough cardiac evaluation of liver transplant candidates is a challenging task, however. Altered cardiac response to stress, heterogeneity and progression of cardiac disease in liver transplant candidates, and the paucity of well-designed studies investigating pre-operative cardiac testing; all explain the current lack of agreement on a single best screening strategy to optimize perioperative outcomes.
This review will discuss the following: profiles of cardiac dysfunction in ESLD, short- and long-term cardiac dysfunction associated with liver transplantation, and the pre-operative evaluation of liver transplant candidates in the light of the current evidence, appraising its limitations. Also, this review will propose avenues for future investigation of cardiac function in liver transplant candidates.
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