Table 1

Pre-Operative Cardiovascular Assessment and Management

Potential CV PathophysiologyDiagnostic Findings and Test Operating CharacteristicsRecommendations
Low HRNoninvasive stress imagingCAD
  • Chronic vasodilatory state

  • Low SVR, low BP

  • Low sensitivity, low NPV of DSE (inability to reach target HR × BP)

  • Low PPV, false positives of SPECT (decreased microvascular reserve)

  • Consideration of invasive or CT coronary angiography if known CAD, abnormal noninvasive test or a high pre-test probability of CAD (DM or ≥2 traditional risk factors)

  • High cardiac output

  • LVH

  • Systolic/diastolic dysfunction

  • LVOTO

  • Echocardiography

  • Subclinical cardiomyopathy (LVH)

  • Inducible LVOTO on DSE

  • Early, reversible systolic dysfunction post-operatively

  • Cardiomyopathy/heart failure

  • Pre-operative TTE to assess systolic and diastolic cardiac function, valves, and left ventricular outflow tract obstruction if LVH; treatment of HF and LVOTO as appropriate

Portopulmonary hypertension (pulmonary arterial HTN)Echocardiography: elevated right-sided and pulmonary pressures. Right-side heart catheterization: mean PAP >25 mm Hg, PVR >3 Wood units in the setting of PCWP <15 mm HgPulmonary heart disease: TTE to assess for pulmonary hypertension, with referral to RHC if elevated PASP or RV systolic dysfunction found on TTE (to differentiate pulmonary venous and pulmonary arterial hypertension) RHC to assess response to medical therapy of confirmed POPH
Pericardial effusionsEchocardiography: potentially decreased PPV for tamponade in setting of POPH ± elevated right-sided pressuresPericardial disease: TTE to assess for pericardial fluid and signs of tamponade
Prolonged QTc intervalElectrocardiography: long QTc, potentially reversible sex differences in QTc abolishedArrhythmia: electrocardiogram to assess baseline QTc interval; treat reversible causes of long QTc
Pre-existing intracardiac shuntEchocardiography: PFO or other intracardiac shuntsIntracardiac shunts: TTE to assess for PFO and other intracardiac shunts; precaution against venous air emboli during transplant procedure

BP = blood pressure; DM = diabetes mellitus; HF = heart failure; HTN = hypertension; LVH = left ventricular hypertrophy; LVOTO = left ventricular outflow tract obstruction; NPV = negative predictive value; PAP = pulmonary arterial pressure; PASP = pulmonary artery systolic pressure; PCWP = pulmonary capillary wedge pressure; PFO = patent foramen ovale; POPH = portopulmonary hypertension; PVR = pulmonary vascular resistance; QTc = corrected QT interval; RHC = right heart catheterization; RV = right ventricular; SVR = systemic vascular resistance; TTE = transthoracic echocardiography.

  • Utility of noninvasive testing for coronary artery disease (CAD) detection in liver transplantation candidates (using coronary angiography as the gold standard): positive/negative predictive values for dobutamine stress echocardiography (DSE) = 22%/75%, respectively (Harinstein et al. [33]), 33%/100% (Donovan et al. [36]), 0%/86% (Williams et al. [35]). Positive/negative predictive values for single-photon emission computed tomography (SPECT) = 22%/77%, respectively (Davidson et al. [38]), 15%/100% (Aydinalp et al. [39]).

  • Traditional risk factors for CAD include age (male >45 years/female >55 years), hypercholesterolemia, hypertension, tobacco use, and family history of early CAD (first-degree relative male <55 years/female <65 years).