Yale University School of Medicine, Cardiovascular Medicine.
Yale University School of Medicine, Transplant Hepatology, Hepatology, Gastroenterology.
Curr Opin Organ Transplant. 2024 Aug 1;29(4):299-304. doi: 10.1097/MOT.0000000000001122. Epub 2023 Nov 23.
This review aims to summarize recent changes in the cardiac evaluation of adult liver transplant candidates. Over the last several years, there have been significant advances in the use of coronary computed tomography angiography (CCTA) with and without fractional flow reserve (FFR) and increasingly widespread availability of coronary calcium scoring for risk stratification for obstructive coronary artery disease. This has led to novel strategies for risk stratification in cirrhotic patients being considered for liver transplant and an updated American Heart Association (AHA) position paper on the evaluation of liver and kidney transplant candidates. The diagnosis of cirrhotic cardiomyopathy has been refined. These new diagnostic criteria require that specific echocardiographic parameters are evaluated in all patients. The definition of pulmonary hypertension on echocardiography has been altered and no longer utilizes right atrium (RA) pressure estimates based on inferior vena cava (IVC) size and collapse. This provides more volume neutral estimates of pulmonary pressure.
Although CCTA has outstanding negative predictive value, false positive results are not uncommon and often lead to further testing. Revised diagnostic criteria for cirrhotic cardiomyopathy improve risk stratification for peri-operative volume overload and outcomes. Refined pulmonary hypertension criteria provide improved guidance for right heart catheterization (RHC) and referral to subspecialists. There are emerging data regarding the safety and efficacy of TAVR for severe aortic stenosis in cirrhotic patients.
Increased utilization of noninvasive testing, including CCTA and/or coronary calcium scoring, can improve the negative predictive value of testing for obstructive coronary artery disease and potentially reduce reliance on coronary angiography. Application of the 2020 criteria for cirrhotic cardiomyopathy will improve systolic and diastolic function assessment and subsequent perioperative risk stratification. The use of global strain scores is emphasized, as it provides important information beyond ejection fraction and diastolic parameters. A standardized one-parameter echo cut-off for elevated pulmonary pressures simplifies both evaluation and follow-up. Innovative transcutaneous techniques for valvular stenosis and regurgitation offer new options for patients at prohibitive surgical risk.
本文旨在总结成人肝移植候选者心脏评估的最新变化。近年来，冠状动脉 CT 血管造影（CCTA）及其分数流量储备（FFR）的应用以及冠状动脉钙评分在预测阻塞性冠状动脉疾病风险分层中的广泛应用取得了显著进展。这导致了用于评估肝和肾移植候选者的美国心脏协会（AHA）更新立场文件中考虑对肝硬化患者进行风险分层的新策略。肝硬化性心肌病的诊断已得到改进。这些新的诊断标准要求对所有患者评估特定的超声心动图参数。超声心动图上肺动脉高压的定义已经改变，不再使用基于下腔静脉（IVC）大小和塌陷的右心房（RA）压力估计。这提供了更具容量中性的肺动脉压力估计。
尽管 CCTA 具有出色的阴性预测值，但假阳性结果并不少见，并且经常导致进一步的检查。肝硬化性心肌病的修订诊断标准改善了围手术期容量超负荷和结局的风险分层。改良的肺动脉高压标准为右心导管检查（RHC）和向专家转诊提供了更好的指导。关于 TAVR 在肝硬化患者严重主动脉瓣狭窄中的安全性和有效性的新兴数据。
增加使用非侵入性检查，包括 CCTA 和/或冠状动脉钙评分，可以提高阻塞性冠状动脉疾病检查的阴性预测值，并可能减少对冠状动脉造影的依赖。应用 2020 年肝硬化性心肌病标准将改善收缩和舒张功能评估以及随后的围手术期风险分层。强调应用整体应变评分，因为它提供了射血分数和舒张参数以外的重要信息。升高的肺压的单一参数超声心动图截止值简化了评估和随访。用于瓣口狭窄和反流的创新经皮技术为高手术风险患者提供了新的选择。
