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Patients undergoing orthotopic liver transplantation (OLT) generally undergo a very thorough preoperative cardiovascular evaluation. Although data is limited, currently guidelines recommend non-invasive stress testing to evaluate for coronary artery disease.
A 54-year old female with a past medical history significant for end-stage liver disease (ESLD) secondary to non-alcoholic steatohepatitis with a model for end-stage liver disease (MELD) score of 15 presented to our facility for OLT evaluation. As part of the patient’s workup cardiovascular risk factors were assessed and the patient was found to have a low-moderate risk for coronary artery disease. A nuclear perfusion study utilizing adenosine was subsequently performed showing a quantitative left ventricular ejection fraction of 70% without any perfusion defects. The patient was ultimately placed on the transplant list without reservation.
Unfortunately, 6 months later the patient presented to the emergency department with substernal chest pain and an electrocardiogram showing evidence of an acute anterior ST-elevation myocardial infarction. Emergent angiography showed a mid-left anterior descending artery stenosis of 99% with a large first diagonal branch with 70% ostial and proximal stenoses. A percutaneous coronary intervention was successfully performed and the patient later underwent OLT without complication.
The cardiovascular workup prior to OLT remains an integral part of the preoperative evaluation. Considering patients with ESLD demonstrate hemodynamic alterations, interpretation of Non-invasive stress testing can be challenging. Our case highlights an uncertainty commonly faced among this patient population and provides additional evidence for further studies.