Impact of Pre-operative Cardiac Testing in Predicting Morbidity Following Elective Liver Transplantation at A South Indian Centre

OBJECTIVES: End- stage liver disease (ESLD)patients undergoing elective liver transplants undergo a number of tests for cardiac evaluation as part of protocol.(1) We sought to assess the impact of pre-operative cardiac testing and interventions(2) on post-operative morbidity outcomes. MATERIAL AND METHODS: Following approval from the IEC (AIMS-2024-033) a retrospective observational study on 158 elective liver recipients between January 2022 and December 2023 at a tertiary care referral centre in South India was included. Patients with acute liver failure, acute on chronic liver failure and pediatric patients (age < 18 y) were excluded. The demographics, MELD scores and tests for cardiac evaluation were noted. Perioperative and postoperative outcomes including ICU stay, cardiac morbidity and all- cause mortality was noted. RESULTS: 158 patients,148 male and 10 female patients were included in the study. Diabetes was present in 77 (49.4%)patients and hypertension in 34 (21.5%) patients. Alcohol was the etiology in 88 (55.7%) and non- alcoholic steato-hepatitis in 29 (18.4%) patients. Thirteen patients had documented coronary artery disease(CAD) at presentation. Prolonged QTc was seen 113(71.5%) patients. All patients had good left ventricular function(EF > 60%) on echocardiography. 78 (49.4%) had left atrial dilatation, 33 (20.9%) had concentric left ventricular hypertrophy and 99 patients had diastolic dysfunction on echocardiography. Dobutamine myocardial perfusion imaging(MPI) was the standard stress test performed although only 115 patients had a rate pressure product (RPP)above 15,000. 18 patients had positive dobutamine MPI and the rest were negative(mean RPP 19050 ± 5605). Fifteen patients underwent coronary angiography and 4 patients underwent percutaneous intervention after angiography. Of this, 1 patient developed renal dysfunction and stress cardiomyopathy in a background of sepsis and 1 developed in-stent thrombosis and infective endocarditis and succumbed. 5 patients had only mild CAD that was medically managed, 3 had normal coronaries and 3 patients underwent angiography due to past history of coronary artery disease. All cause mortality was 18.98% (n = 30) at 90 days. Sepsis relating to graft dysfunction was the commonest with 12.6% (20) patients. Only 5 (3%)patients died due to cardiac causes, suspected massive pulmonary embolism (n = 1), stress cardiomyopathy in a background of sepsis (n = 2), NSTEMI (n = 1)and infective endocarditis with in-stent thrombosis(n = 1). Other causes of mortality included hepatic artery thrombosis(n=1), portal vein thrombosis(n = 1) and primary non function(n = 1), hepatic artery pseudo aneurysm(n = 1) and encephalitis (n = 1). CONCLUSION: Cardiac causes of mortality appear to be low in the peri-operative period after liver transplantation in this population. Dobutamine MPI can identify patients with CAD although target RPP may not be obtained. Percutaneous interventions can be judiciously performed in select situations with critical lesions and medical management when appropriate appears to be safe.