Cardiac or pulmonary vascular condition |
Diagnostic modality |
Test operating characteristicsc |
Special considerations in ESLD |
GRADE recommendations |
PPV |
NPV |
Coronary artery disease |
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LT candidates with DM or ≥2 traditional cardiac risk factorsa are most likely to have obstructive CAD |
Consider invasive or noninvasive angiography if known CAD, abnormal noninvasive test or a high pretest probability of CAD (DM or ≥2 traditional risk factors) (2C) |
Noninvasive stress testing DSE Vasodilator testingd |
0%-33% 15%-22% |
75%-100% 77%-100% |
LT candidates may not achieve maximal chronotropy on pharmacologic stress testing Resting microvascular vasodilation limits available coronary flow reserve |
The decision to pursue stress testing should be based on individualized evaluation of the candidate's pretest probability for having CAD (see above) (1C) |
Functional testing Cardiopulmonary exercise testing (CPET) |
Unknown |
Unknown |
VO2 max, a measure of CV fitness, is achieved in <35% of patients with ESLD; VO2 peak can be used as a surrogate31 Anaerobic threshold (AT), a measure of cardiopulmonary reserve, can be obtained in >90% of patients with ESLD Reduction in VO2 peak <15 mL/min per kg places a patient in class III-IV heart failure category and predicts poor prognosis Reduction in aerobic capacity predicts outcomes in waitlist candidates and at 90 and 100 d post-LT |
For ambulatory patients, functional testing may be useful to identify those LT candidates who are at increased risk for poor outcomes and who may benefit from prehabilitation (2C) |
6-minute walk test (6MWT) |
Unknown |
Unknown |
-AT <9.0 mL/min per kg is associated with reduced 90-d survival -AT of <9.2 mL/minute per kg is associated with increased length of hospital stay 6MWD < 250 meters is associated with increased risk of death For each 100-meter increase in 6MWD survival increases by 42% (HR, 0.58; P = .02)35 |
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Noninvasive coronary CT angiography (CCTA) Coronary artery calcium (CAC) score |
17%b |
95%b |
CAC score > 400 HU predicts: -Significant CAD requiring revascularization36 -1 month post-LT complications (OR, 95% CI: 4.62, 1.1–18.7)37 |
Consider CCTA in patients with normal body habitus who are able to lie still, perform required breath-holding maneuvers, and who have a regular nontachycardic rhythm (2C) In candidates with advanced CKD and suspected CAD, consultation with a nephrologist and standard preventive measures for contrast-induced nephropathy are recommended (1C) |
Invasive coronary angiography |
NA |
NA |
Invasive angiography, when indicated, is safe despite coagulopathy and renal dysfunction. |
To reduce bleeding complications, a transradial approach (if possible) and minimization of sheath size are recommended (1C) Bare metal stents are preferred to minimize duration of dual antiplatelet therapy, though drug-eluting stents may also be used (1C) In candidates with advanced CKD and suspected CAD, consultation with a nephrologist and standard preventive measures for contrast-induced nephropathy are recommended (1C) Patients who have been revascularized surgically with coronary artery bypass grafting should be treated based on their pretransplant assessment of left ventricular ejection fraction and ischemic testing. If testing yields a reduction in systolic function or evidence of ischemia, then invasive testing should be performed to assess graft patency (1C) |
Cardiomyopathy and heart failure |
2-Dimensional echocardiography (TTE) |
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May detect diastolic dysfunction (hallmark of CC)LVOTO > 36 mm Hg increases risk for intraoperative hypotension LVH may suggest subclinical myocardial diseaseIncreased LA volume is a predictor of future heart failure events |
Preoperative TTE should be performed in all candidates to assess systolic and diastolic cardiac function and LVOTO (1C) Detected abnormalities require a multidisciplinary approach as to the cause of findings, further testing. and initiation of heart failure therapies (1C)Presence of CC should be considered in the decision-making process when listing patients for LT (2C) |
DSE |
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May detect systolic dysfunction manifested by a decrease in stroke volume or ejection fraction LVOTO may be inducible |
The decision to pursue stress testing should be based on individualized evaluation of the candidate's pretest probability for having inducible systolic dysfunction (1C) |
12-lead ECG |
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QTc prolongation (>440 ms) is the hallmark of CC and predicts post-LT cardiac complications Impaired excitation contraction coupling may be seen in CC; clinical significance unknown |
Treat reversible causes of prolonged QTc and avoid QT prolonging medications (1C) |
Functional testing Cardiopulmonary exercise testing (CPET) 6-minute walk test (6MWT) |
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|
Alteration of aerobic capacity (VO2 peak) or ventilator efficiency (VE/VCO2) is a sign of CC Reduced exercise tolerance is a sign of CC |
For ambulatory patients, functional testing may be useful to identify those LT candidates who are at increased risk for poor outcomes and who may benefit from prehabilitation (2C) |
Portopulmonary hypertension |
2-Dimensional echocardiography (TTE) |
Elevated right-sided and pulmonary pressures (RVSP > 40–50 mm Hg) In patients with PoPH, RVSP overestimates PAP at higher levels of RVSP (r = 0.43)93 |
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Referral for RHC if elevated RVSP (>40–50 mm Hg) or RV systolic dysfunction found on TTE (1C) |
Right-side heart catheterization |
MPAP>25 mm Hg, PVR >240 dynes/s per cm−5 with PCWP <15 mm Hg |
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MPAP >35 mm Hg and PVR >400 dynes/s/cm−5 on RHC is a contraindication to LT |
POPH should only be diagnosed on RHC (1C) RHC should assess response to medical therapy of confirmed PoPH (1C) A multidisciplinary team approach with experts in anesthesia and pulmonary hypertension is critical in the management of patients with POPH (1C) |
Cardiac arrhythmias |
12-lead ECG |
QTc prolongation:>0.45 s males or >0.47 s females |
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AF prevalence is 1%-6% in LT candidates and is associated with a 6-fold increased odds of post-LT complications Prolonged QTc may be acquired or congenital and is common in CC |
Arrhythmia on ECG should prompt a thorough history and investigation of associated causes (1C) In patients with known dysrhythmias, perioperative hemodynamic monitoring with treatment readily at hand, such as transcutaneous or transvenous pacing, electrical cardioversion or defibrillation, and appropriate anti-arrhythmic drugs is recommended (1C) |
Valvular heart disease |
2-Dimensional echocardiography (TTE) |
28% of LT candidates have mitral or triscuspid regurgitation |
|
TR is associated with poorer post-LT outcomes Mild or moderate asymptomatic AS is not an absolute contraindication to LT |
TTE should be performed in all patients to assess for valvular disease (1C) Intraoperative TEE may be a useful adjunct in the management of patients with valvular heart disease undergoing LT (2C) |