The following are key points to remember from a state-of-the-art review on cardiovascular disease (CVD) assessment and management in liver transplantation:

1. The prevalence of end-stage liver disease (ESLD) is rising globally. The ESLD population is becoming older, with more comorbidities, and the proportion of patients undergoing liver transplant (LT) for metabolic dysfunction-associated steatohepatitis is rising. CVD is one of the three main causes of morbidity and mortality after LT, with a prevalence as high as 30% at 8 years post-LT.
2. Perioperatively, LT patients are exposed to major hemodynamic stressors, blood loss, electrolyte disturbances, and an inflammatory milieu, increasing the risk of CV events. Pre-LT CV workup strategies vary widely among centers, and data to inform these strategies are sparse. This state-of-the-art review attempts to provide guidance to clinicians and highlight areas deserving of future research.
3. Three LT-specific CV risk scores exist: CAD-OLT, CAD-LT, and CARI. The CAD-LT score was designed to predict significant coronary artery disease (CAD) (c-statistic 0.72-0.76) and takes into account risk factors such as age, diabetes, hypertension, and smoking.
4. For all LT candidates, preoperative electrocardiography and transthoracic echocardiography (TTE) are recommended.
5. The authors recommend preoperative CAD screening for most LT candidates, with the exception of those who are <40 years of age and have no CV risk factors. For patients >60 years old or with ≥2 CV risk factors, the authors recommend anatomic evaluation of the coronary arteries with coronary computed tomography angiography or invasive coronary angiography. Dobutamine stress echocardiography, while widely used in the pre-LT population, has poor sensitivity for significant CAD. Vasodilator-based myocardial perfusion imaging methods may be limited in accuracy due to resting vasodilation in ESLD, though the authors do not specifically address the potential role of positron emission tomography perfusion imaging, which is less widely available than single-photon emission computed tomography.
6. Decisions regarding coronary revascularization prior to LT should be made by an interdisciplinary team, carefully weighing benefits and risks, including bleeding.
7. Cirrhotic cardiomyopathy is most often subclinical, but overt myocardial dysfunction can be unmasked by the stressors of LT surgery. On echocardiography, cirrhotic cardiomyopathy may manifest as either left ventricular systolic dysfunction (ejection fraction <50% or global longitudinal strain <18%) or diastolic dysfunction (any three of the following: E/e’ ≥15, left atrial volume index >34 mL/m², septal e’ <7 cm/s, tricuspid regurgitation maximum velocity >2.8 cm/s). Identified cardiac dysfunction should be managed according to guidelines, though use of renin-angiotensin-aldosterone system inhibitors are often limited by concomitant kidney disease.
8. For management of aortic stenosis in the pre-LT population, transcatheter aortic valve implantation is a reasonable treatment option, particularly as surgical aortic valve replacement may present unacceptable risks in the setting of ESLD.
9. Screening for pulmonary hypertension (PH) should begin with assessment of peak tricuspid regurgitation velocity on TTE, with consideration of right heart catheterization if multiple indicators of PH are present (e.g., dilation of the right heart chambers, interventricular septal flattening). If moderate to severe PH (mean pulmonary artery pressure ≥35 mm Hg) is present despite management of volume overload, a PH specialist should be consulted.
10. The reported incidence of intraoperative cardiac arrest during LT is 1-5%, with the highest risk occurring during the post-reperfusion period. Intraoperative transesophageal echocardiography can provide valuable diagnostic information in this setting.
11. Arrhythmias, predominantly atrial fibrillation (AF), account for 40-50% of early post-LT cardiac events. Postoperative AF usually occurs within 24-72 hours of surgery. Beta-blockers and amiodarone are often used, but non-dihydropyridine calcium channel blockers should be avoided in LT recipients due to drug-drug interactions with calcineurin inhibitors. Risks and benefits of anticoagulation and the timing of initiation should be carefully weighed by an interdisciplinary team.
12. For up to 1 year in the post-LT period, use of aspirin (81-162 mg daily) is recommended to prevent hepatic artery thrombosis.

Clinical Topics: Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD)

Keywords: Coronary Artery Disease, Diagnostic Imaging, End Stage Liver Disease, Liver Transplantation

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