Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions.

In the changing landscape of liver transplantation, we are now evaluating older and sicker patients with more cardiovascular comorbidities and the spectrum of cardiovascular disease is uniquely physiologically impacted by end-stage liver disease. Cardiac complications are now the leading cause of morbidity and mortality in liver transplant recipients and the pre-transplant risk is exacerbated immediately during the transplant operation and continues long term under the umbrella of immunosuppression. Accurate risk estimation of cardiac complications prior to liver transplantation is paramount to guide allocation of limited healthcare resources and to improve both short- and long-term clinical outcomes for patients. Current screening and diagnostic testing are limited in their capacity to accurately identify early coronary disease and myocardial dysfunction in persons with end-stage liver disease physiology. Furthermore, a number of testing modalities have not been evaluated in patients with end stage liver disease. As a result, there is wide variation in cardiac risk assessment practices across transplant centers. In this review, we propose a definition for defining cardiac events in liver transplantation, evaluate the current evidence for surgery-related, short- and long-term cardiac risk assessment in liver transplant candidates, propose an evidence-based testing algorithm and highlight specific gaps in knowledge and current controversies, identifying areas for future research.