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World J Transplant. Jul 18, 2022; 12(7): 142-156
Published online Jul 18, 2022. doi: 10.5500/wjt.v12.i7.142
Cardiac risk stratification of the liver transplant candidate: A comprehensive review
Sanjana Nagraj, Spyros Peppas, Maria Gabriela Rubianes Guerrero, Damianos G Kokkinidis, Felipe I Contreras-Yametti, Sandhya Murthy, Ulrich P Jorde
Sanjana Nagraj, Maria Gabriela Rubianes Guerrero, Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
Spyros Peppas, Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
Damianos G Kokkinidis, Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
Felipe I Contreras-Yametti, Department of Medicine, Wellstar Atlanta Medical Center, Atlanta, GA 30312, United States
Sandhya Murthy, Ulrich P Jorde, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
Author contributions: Nagraj S, Peppas S, Kokkinidis DG, Rubianes Guerrero MG, Contreras-Yametti FI, Murthy S, and Jorde UP contributed to the conceptualization, methodology, validation of the manuscript; Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, and Contreras-Yametti FI involved in manuscript writing original draft; Kokkinidis DG, Murthy S, and Jorde UP contributed to the manuscript writing, review editing and supervision; and all authors have read and approve the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Sanjana Nagraj, MBBS, Doctor, Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, New York City, NY 10461, United States.
Received: January 13, 2022
Peer-review started: January 13, 2022
First decision: June 6, 2022
Revised: June 15, 2022
Accepted: June 23, 2022
Article in press: June 23, 2022
Published online: July 18, 2022

Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.

Keywords: Cardiovascular risk, Liver transplantation, End stage liver disease, Liver cirrhosis, Cardiovascular diseases, Cardiovascular diagnostic techniques

Core Tip: Liver transplantation is high-risk invasive procedure with an increased likelihood of cardiovascular mortality in the perioperative and postoperative periods. As the predominant etiology of end-stage liver disease and attributes of transplant candidates continue to evolve, cardiac risk stratification of these patients is becoming increasingly relevant. This review aims to reach providers seeking to learn about the current state of cardiac assessment of liver transplant candidates, commonly encountered cardiovascular conditions, preoperative diagnostic testing, and patient optimization. We also highlight areas requiring further investigation.