Author + information
- Matthew E. Harinstein, MD,
- Zankhana Raval, MD,
- Mihai Gheorghiade, MD and
- James D. Flaherty, MD⁎ ()
- ↵⁎Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, 251 E. Huron Street, Galter 8-130, Chicago, Illinois 60611
We appreciate the comments of Dr. Joshi and colleagues regarding our report on the cardiovascular risk assessment of candidates for liver transplantation (1).
We agree that liver transplantation in patients with severe left ventricular systolic dysfunction carries a higher risk for cardiovascular complications and mortality. These patients should be thoroughly evaluated, as we have described, and would benefit from referral to higher volume transplantation centers with experience in caring for such patients. As noted in our report, and by Joshi et al., there have been case reports of successful transplantation in such patients, often requiring combined liver and heart transplantation (2). Several potential etiologies of systolic dysfunction in patients with end-stage liver disease have been described, and some may be reversible (3,4). Therefore, we do not consider severe systolic dysfunction to be an absolute contraindication to liver transplantation. However, liver transplantation in this patient type should be undertaken only at centers with advanced heart failure programs.
With regard to the utility of the measurement of oxygen consumption at peak exercise to assess aerobic capacity, this is certainly another piece of information that can be added to the cardiologist's armamentarium when performing a cardiovascular risk assessment of a liver transplantation candidate. In a multivariate analysis, it was associated with 1-year survival and was also associated with post-operative complications in sicker patients (5). Although we do not believe that this should be a sole reason for exclusion for liver transplantation candidacy, we agree that it may aid in assessing cardiovascular risk.
- American College of Cardiology Foundation