Abstract
Background
Cardiovascular (CV) risk stratification in patients with end-stage liver disease (ESLD) prior to liver transplantation (LT) is crucial: CV-disease poses a major threat for posttransplant survival.
Therefore, our purpose was to assess safety of coronary computed tomographic angiography (CTA) in patients prior to orthotopic LT over a long-term follow up period, and its value for CV risk stratification.
Methods
In this single center, retrospective observational study 458 patients underwent coronary calcium score (CCS) and coronary CTA for pre-LT risk stratification between 2005 and 2016. CTA was evaluated for 1) stenosis severity (CADRADS: 4-severe>70%/3-intermediate50–70%/2-mild<50%/1-minimal<25%/0=no CAD) 2) plaque burden (SIS, G-score), 3) high–risk plaque features (Napkin Ring Sign, low attenuation plaque, positive remodelling) and 4) Coronary Calcium Score. Primary endpoint was mortality (all-cause and cardiovascular), secondary endpoint major cardiovascular events (MACE).
Results
Finally 270 patients (79.3% males, age 61±8.5 years) who underwent orthotopic LT were included (mean follow-up 7.5 years±3.1, range 2–13). 87 (32.2%) had CCS zero and 60 (22.2%) CCS >300 Agatston Units (CCS 335.6 AU± 868.9). 248 patients underwent CTA after CCS. The majority had CAD (n=173, 72.3%) by CTA while only 75 (27.7%) had no CAD. 102 patients (38.8%) had minimal-or-mild stenosis<50% (CADRADS 1–2), 34 (12.9%) intermediate and 17 (6.5%) severe stenosis.Out of CCS 0 patients, 13 had non-calcified plaque.
All-cause mortality rate was 46 (17.0%), with the majority of patients (43 (93.5%) experiencing non-cardiac death and 3 (6.5%) cardiovascular death due to 1 myocardial infarction and 2 cardiopulmonary failure. CADRADS predicted mortality (Kaplan Meir, p<0.001). On multivariate Cox Regression modell, SIS and G-score predicted all-cause mortality (HR 1.1:p=0.034; 95% CI: 0.649–0.983 and HR 1.1, p=0.029; 95% CI: 1.0–1.6), while Calcium Score did not. There were 6 MACE (3 STEMI, 3 NSTEMI). MACE rate was 0% in CADRADS 0 or 1, 1 in CADRADS-2 and increasing to 5 in CADRADS 3 and 4 groups.
Coronary CTA for LT risk stratification
Conclusion
Cardiac CT is a reliable non-invasive modality for pre-LT assessment of CV-risk over a long-term period, with 0% MACE in patients with no CAD or minimal CAD. CTA allows for an improved CV-risk stratification by stenosis severity (CADRADS) and plaque burden as compared to calcium scoring.
Coronary calcium score in symptomatic patients referred for a coronary computed tomographic angiography. Influence of diabetes
