Liver transplantation and atrial fibrillation: A meta-analysis

Table 1 Main characteristic of studies included in meta-analysis of atrial fibrillation and liver transplantation

	Fouad et al[24]	VanWagner et al[25]	Nicalau-Raducu et al[26]	Josefsson et al[27]
Country	Canada	United States	United States	Sweden
Study design	Retrospective Cohort	Case-Control	Retrospective Cohort	Retrospective Cohort
Yr	2009	2012	2014	2014
Total number	197	242	389	186
Mean age ± SD	56	55	55	52
Duration (yr)	6 mo	1 yr	3.4	4
Outcome definition	Cardiac complication after LTx	CV complication after LTx	Early (< 1 yr) and Late (> 1 yr) post LTx AF	Incident cardiac event post LTx
Outcome ascertainment	Review EKG in medical records	EKG, Echo, LHC, RHC, DSE as indicated	Review medical records	Review medical records
Incidence of pre-operative AF	NA	All 12/242 (5.0%) NASH 7/115 (6.1%) Alcohol 5/127 (3.9%)	NA	Atrial fibrillation/flutter 4/186 (2.2%)
Incidence of post-operative AF	Intraoperative 1/197 (0.5%) Early postoperative (0-30 d) 3/197 (1.5%) Late postoperative (1-6 mo) 2/197 (1.0%)	All 21/242 (8.7%) NASH 11/115 (9.6%) Alcohol 10/127 (7.9%)	All 12/389 (3.1%) Early (< 1 yr after transplant) 10/389 (2.6%) Late (> 1 yr after transplant) 2/389 (0.5%)	Arrhythmia (mainly AF or flutter) All 36/186 (19.4%) Peri-transplant 24/186 (12.9%) Late 12/186 (6.5%)
Outcomes	NA (study aim to identify predictor of cardiac complication 6 mo after LTX)	NA (study aim to compare CV event between liver disease before liver transplant)	NA (study demonstrated target DSE prior liver transplant associated with increased risk of AF)	NA (study aim to assess pretransplant EKG as a predictor of post liver transplant event)
Confounder adjustment	NA	NA	NA	NA
Newcastle-Ottawa scale	S3 C0 O3	S4 C2 O3	S3 C3 O3	S4 C2 O3
	Vannucci et al[20]	Bargehr et al[21]	Xia et al[22]	Piazza et al[23]
Country	United States	United States	United States	Italy
Study design	Retrospective Cohort	Case-Control study	Retrospective Cohort	Retrospective Cohort
Yr	2014	2015	2015	2016
Total number	757	717	1387	143
Mean age ± SD	57.9 ± 6.8	58	54	55
Duration (yr)	1 yr	NA	30 d	3
Outcome definition	30 d and 1-yr survival after Liver Tx.	Cardiac complication after LTX	POAF (postoperative AF in LTX)	Incident AF (also other CVE) in NASH and alcoholic s/p LTx
Outcome ascertainment	Medical records	Review Medical records	EKG, Holter and medical records	Review medical records
Incidence of pre-operative AF	19/757 (2.5%)	32/717 (4.5%)	77/1387 (5.6%)	Alcoholic cirrhosis 2/65 (3.1%) NASH cirrhosis 3/78 (3.8%)
Incidence of post-operative AF	NA	1/63 (1.6%)	New onset AF within 30 d after LT 102/1387 (7.4%)	2/143 (1.4%)
Outcomes	1-mo mortality 5.29 (1.73-16.18) 1-yr mortality 3.28 (1.63-6.59)	Intraoperative cardiac complications 7.83 (1.94-31.49) Mortality 1.50 (0.61-3.69)	Median Hospital stays 31 d (16-67) in POAF vs 20 d (12-37) AKI 2.5 (1.06-5.70) Mortality 2.36 (1.45-3.85) Graft failure 2.28 (1.44-3.59)	NA (study aim to compare outcome as CV event after liver transplant between patients with NASH and those with alcoholic cirrhosis who receive liver transplant)
Confounder adjustment	NA	Age, MELD, donor risk index, DM	Age, MELD, intraoperative blood transfusion	NA
Newcastle-Ottawa scale	S3 C0 O3	S4 C2 E3	S4 C2 O3	S4 C2 O3
	VanWagner et al[28]	VanWagner et al[31]	VanWagner et al[29]	Wange et al[30]
Country	United States	United States	United States	Sweden
Study design	Retrospective Cohort	Case Control	Retrospective Cohort	Retrospective Cohort
Yr	2016	2017	2018	2018
Total number	32810	1024	671	63
Mean age ± SD	55 ± 10	56	Various by renal disease classification group	45
Duration (yr)	90 d	1 yr	NA	10
Outcome definition	MACE after Liver transplantation	CVD complication vs No CVD complication group	1-yr CV complication	Incident AF post LTx who survive > 3 yr (LTx ATTRm amyloidosis)
Outcome ascertainment	Medical record in patient admitted by MACE	EKG, Holter and medical records	Medical record	Echo and Holter every visit
Incidence of pre-operative AF	1969/32810 (6.0%)	62/1024 (6.1%)	2145/37322 (5.7%)	1/63 (1.6%)
Incidence of post-operative AF	204/32810 (0.6%)	130/1024 (12.7%)	65/671 (9.7%)	Incident AF 20/63 (31.7%) All AF post-op 21/63 (33.3%) (Median diagnosis 2 yr)
Outcomes	Pre-transplant AF and 30-d MACE (MI, HF, AF, cardiac arrest, PE, stroke) 6.9 (5.0-9.6) Pre-transplant AF and 90-d MACE 6.1 (4.5-8.3)	Pre-transplant AF and CVD complication 8.96 (3.70-22.0)	NA (study aim to assess degree of renal disease to 1-yr CV outcome in liver transplant patient)	Cerebrovascular events (TIA, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) 3.8 (1.1-9.5)
Confounder adjustment	Sex, age, history of stroke, type of cirrhosis, and pre- transplant creatinine	Age, sex, race, working status, education, respiratory failure on ventilator at transplant, pulmonary hypertension, HCC, hypertension, DM, heart failure	NA	Cardiomyopathy, ischemic heart disease
Newcastle-Ottawa scale	S3 C0 O3	S4 C2 E3	S4 C2 O3	S3 C0 O3

ATTRm: Amyloid-forming variant Transthyretin proteins; CVD: Cardiovascular disease; HCC: Hepatocellular carcinoma; HF: Heart failure; MACE: Major adverse cardiovascular event; MI: Myocardial infarction; AF: Atrial fibrillation; DSE: Dobutamine stress echocardiogram; EKG: Electrocardiogram; LTX: Liver transplantation; NASH: Nonalcoholic steatohepatitis; NA: Not available; RA: Right atrium; S: Selection; C: Comparability; O: Outcome; AKI: Acute kidney injury; POAF: Post-operative atrial fibrillation; MELD: Model for End Stage Liver Disease.