Author + information
- Deepak Joshi, MB BS⁎ (, )
- Chris Willars, MB BS,
- William Bernal, MD,
- Julia Wendon, MD and
- Georg Auzinger, EDIC
- ↵⁎King's College Hospital, Liver Intensive Care Unit, Denmark Hill, London, United Kingdom
We read with great interest the report by Raval et al. (1) on cardiovascular risk assessment of candidates for liver transplantation (LT) and would like to congratulate the investigators on a comprehensive and thorough review.
We disagree, however, with a comment made in the section on heart failure and cardiomyopathy and the evidence provided in the report. The investigators, quite rightly, recommend that all patients undergo pre-operative transthoracic echocardiography, a practice routinely undertaken at LT centers. They then state that patients with left ventricular ejection fractions as low as 10% have successfully undergone LT after aggressive medical management, citing a Canadian case series (2). We believe this deserves further analysis. The publication describes 4 patients with end-stage hypertrophic, dilative, and ischemic cardiomyopathy who underwent combined cardiac transplantation and LT on cardiopulmonary bypass. All patients were highly symptomatic, with New York Heart Association functional class III or IV heart failure, and 3 had congestive cirrhosis due to right ventricular failure. It appears as if the primary indication for transplantation was cardiac, but heart transplantation alone was not possible, because of end-stage liver disease. We believe that the term “aggressive medical management” is misleading in this context and does not appropriately describe the complexity of the procedures performed. We strongly believe that severe and symptomatic heart failure is an absolute contraindication for LT, unless a combined heart and liver transplantation procedure is considered.
In the section on recommendations for assessment, the role of cardiopulmonary exercise testing, in particular the assessment of aerobic capacity, was not commented on. The most sensitive index of aerobic capacity is oxygen consumption at peak exercise (peak Vo2). Evaluation of peak Vo2 is increasingly used at LT centers as part of the routine assessment. Dharancy et al. (3) demonstrated that a peak Vo2 of <60% was associated with reduced 1-year survival in patients listed for LT. The predictive ability of peak Vo2 was more evident in patients with Model for End-Stage Liver Disease scores >17.
In summary, severe left ventricular failure remains in our view an absolute contraindication for LT despite aggressive medical management. Dynamic cardiopulmonary testing and assessment of aerobic capacity provides important prognostic information and should be considered in all patients undergoing elective LT assessment.
- American College of Cardiology Foundation