Abstract 4509: Cardiac Catheterization as a Strategy for Pre-Operative Risk Stratification in Patients Undergoing Liver Transplantation
Liver transplantation (LT) is considered a high risk surgery due to the hemodynamic and cytokine stress on the recipient coronary arteries. Limited data exists on the role of cardiac catheterization and percutaneous coronary intervention (PCI) as a pre-LT risk stratification strategy to improve clinical outcomes in these patients. Retrospective single center observational study of 982 patients who underwent LT between January 2000 to January 2008. The most common indications for LT were alcoholic liver cirrhosis, non-alcoholic fatty liver disease and hepatitis C. The outcomes evaluated were death, MI and a composite endpoint (death, MI or stroke). Median follow up was 32 months. Of the 982 patients, 317 patients (32%) had coronary angiography prior to LT. Patients who had coronary angiography were older, had a higher prevalence of coronary risk factors, history of prior CAD and were more likely to have an abnormal stress test. Among those who had cardiac catheterization, 67% had no significant CAD, 14% had mild disease (≤50% stenosis), 6% had moderate disease (>51% but <70% stenosis) and 13% severe disease (≥70% stenosis). Patients who underwent cardiac catheterization had lower mortality than those who did not undergo catheterization (15% vs 21%, p=0.02). Thirty five out of 317 patients (11%) had PCI after undergoing cardiac catheterization. The overall mortality was not significantly different in patients who underwent PCI compared to those who did not undergo PCI (23% vs 14%, p=0.2). However, PCI was associated with a higher incidence of the composite endpoint of death, MI or stroke (40% vs 23%, p=0.04). Pre-operative cardiac catheterization was associated with reduced mortality in patients undergoing LT. Catheterization identified severe CAD in 13% of the patients. Although PCI permitted many of these patients to undergo LT, it did not improve mortality and was associated with a higher incidence of the adverse composite endpoint of death, MI or stroke. These findings suggest that routine cardiac catheterization may improve mortality predominantly by better identification of patients for LT, optimal selection of healthier donor livers for patients with CAD and optimization of peri-operative medical therapy.