Coronary and Cardiac Screening In Liver Transplantation Candidets: A Long Journey with Frequent Identification of Moderate and Severe Coronary Artery Disease

Background: In patients (pts) with Liver cirrhosis (LC) CV risk stratification before major liver surgery (Liver Transplantation and Liver resection) is a complex task due to the unique cardiovascular physiology of this subset of pts, and is aimed to detect coronary artery disease (CAD) and nonCAD cardiac abnormalities. NASH is a faster-growing indication for liver transplantation and is an independent risk factor for presence of obstructive CAD. LC pts often show anemia and platelets (PP) reduction, that may impact on risk related to invasive vascular procedures, such as PCI/CABG. Aims: to describe in LC pts: 1) temporal shifts (2013-2023) in etiological LC burden; 2) features of non-ST parameters at exercise stress test reflecting functional capacity; 3) tools/tests used and duration required for assessment of CV risk; 4) incidence of anemia, low PP count (<100 109/L) and CAD. Methods: Ambispectic Single-Centre Study collecting data on exercise EKG parameters ( MET at peak, maximal heart rate incompetence [MHR-I], heart rate recovery at 1 min [HRR1’] ) in 194 LC pts (age 59.8±10.3), 125 CONTR (58.2±15.6) and 18 CHF (72.1±11.2). Within LC pts, multiple noninvasive (exercise stress testing, myocardial perfusion imaging [MPI], pharmacological Stress echocardiography [Echo-stress]) and invasive modality of imaging and of stress testing were used. Coronary computed tomography angiography (CT) to derive Ca-score and coronary stenosis and invasive coronary angiography (ICA) were used to quantify CAD presence and critical CAD. Results Metabolic cause (NASH) of LC moved overtime from 2.7% to 21.9% while viral (HBV/HCV) and EtOH causes moved from 12%/39% and 23% to 6%/16% and 38%. Exercise Stress test parameters collected within study groups (CONTR, LC, CHF) are: MET peak: 7.1±1.8, 5.0±1.6, 4.5±1.2; MHR-I: 0.76±0.15, 0.57±0.23, 0.65±0.21; HRR1’: 21.1±8.7, 13.7±7.5, 10.9±7.9 (p<0.01 CONTR vs other groups). Time required (days) for cardiac consult to rule in/out access to liver surgery is 3±6 days for those undergoing visit+Echo only; with additional testing: 51±54 +CT/ICA, 61±60 + Echo-stress, 63±61 + MPI and 89±69 +PCI. Within LC pts undergoing coronary imaging: Hb levels (g/L) and PP count (109/L) are (IQ 25-50-75) 111-125-138 and 68-104-162; Ca-score at CT is 0-99 (19.5%), 100-399 (11%), >400 (69.5%); CAD identified is subcritical 39.1%, intermediate 21.8%, critical 31.1%, PCI and stenting are done for 1V/2V disease (76.9%/23.1%) and in proximal/non proximal segments 46%/56%, with no complications in pts with low PP count. Conclusions An increase of metabolic burden has been observed overtime in the LC pts; functional capacity is reduced in LC pts, and the blunted chronotropy and reduced cardiorespiratory fitness, similar between LC and CHF pts, result in low sensitivity and suboptimal negative predictive value for the detection of coronary artery disease; significant CAD is better searched with noninvasive or invasive coronary angiography. Collecting cardiac information may be a time-consuming task, requires 3-89 days and includes search for presence of CAD in 50% LC pts. In CAD pts, PCI is done at proximal segments in 46% LC pts, and the frequent finding of count of PP < 100 109/L was not associated to excess in bleeding risk.