Cardiovascular disease in liver transplant candidates

Author: Fadak Mohammadi

Mohammadi, Fadak, 2024 Cardiovascular disease in liver transplant candidates, Flinders University, College of Medicine and Public Health

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Cardiovascular disease (CVD) in liver transplant (LT) candidates is increasingly recognised as a leading cause of morbidity and mortality before and after transplantation. Heart failure and significant arrhythmias contribute up to 50% of heart related hospitalisations in the early post-transplant period. Over time, the accumulation of cardiac risk factors results in coronary artery disease (CAD) post-transplant. The changing demographics of patients being considered for LT, such as older patients, increasing non-alcoholic fatty liver disease (MAFLD), and pre-existing CAD, make cardiac risk an important consideration in LT candidates. MAFLD is increasingly recognised for its association with CVD, including the higher risk of CAD and as an independent risk factor for heart failure. Cirrhotic cardiomyopathy (CCM) is also an increasingly recognised extra-hepatic complication of cirrhosis. CCM is defined as the presence of systolic and/or diastolic dysfunction (DD) in cirrhotic patients in the absence of other causes of cardiac dysfunction. While typically subclinical, it can present as overt cardiac failure under stressors such as LT, use of beta blockers and trans-jugular intrahepatic portosystemic shunting (TIPSS).

The first chapter of this thesis covers the different causes of cardiac dysfunction in cirrhosis and the cardiac considerations in pre-, peri- and post-transplant settings. The second chapter of this thesis highlights the impact of cardiac dysfunction on morbidity and mortality of LT candidates, and the incidence of post-transplant CVD over the past 10 years in the South Australian Liver Transplant Unit (SALTU). The third chapter describes the management and clinical outcomes of LT candidates with pre-existing CAD, including post-transplant CAD, over the past 10 years in the SALTU. The fourth chapter reviews the evidence and changes in cardiac evaluation of LT candidates based on international guidelines and presents a risk factor based diagnostic pathway than can be implemented in SALTU successfully, with the aim of improving management of CVD in LT candidates. Finally, a summary and recommendations for areas of further investigation will be presented to conclude this thesis.

Keywords: cardiovascular, cirrhosis, liver, transplant, liver failure, cardiac, coronary, cardiomyopathy

Subject: Medicine thesis

Thesis type: Masters
Completed: 2024
School: College of Medicine and Public Health
Supervisor: Jeyamani Ramachandran