Cardiac CT Angiography is a feasible study in high-risk patients undergoing liver
transplantation and can provide additional information to Dobutamine Stress Echography.
Introduction: In patients undergoing liver transplantation (OLT), underlying coronary artery disease
(CAD) is associated with a high risk of morbidity and mortality and is a relative contraindication to
the procedure. Prior to liver transplantation cardiovascular evaluation in patients at high risk of CAD
is generally accomplished by dobutamine stress echocardiography (DSE). The role of cardiac CT
Angiography (CTCA), a non-invasive imaging procedure that has been shown to be accurate in the
detection and quantification of haemodynamically significant coronary artery stenoses has not been
clearly evaluated in this patient population.
Aims: To assess the feasibility and outcome of CTCA in patients at high risk of CAD undergoing
assessment for liver transplantation.
Methods: Between 2010 and 2013, 40 patients underwent DSE and CTCA as part of liver
transplantation work-up. Patients received beta-blockers for heart rate control and nitroglycerin for
dilation of coronary vessels as per a standard CTCA protocol. Atherosclerotic lesions were evaluated
for severity, morphology, extent, location and consistency. Medical records were analysed to
determine cardiac risk factors, reason for transplantation and outcomes.
Results: The median patient age was 60.5 years (range 44-67 years) and 85% (34) were male.
Indications for liver transplantation assessment were hepatocellular carcinoma, hepatitis C, alcohol or
hepatitis B (n=21, 19, 15, 4 respectively). Documented cardiac risk factors included diabetes (50%),
smoking (58%), hypertension (30%), hypercholesterolemia (5%), family history of ischaemic heart
disease (IHD) (32.5%), personal history of IHD (10%) and obesity (10%). 70% (28) of patients had
≥2 risk factors. CTCA was successfully performed in 36 (90%) patients; the procedure was
abandoned in 4 patients due to tachycardia. 72% (26) were normal or showed non-obstructive (<50%
stenosis) coronary plaque. 28% (10) showed at least one obstructive coronary plaque (>50% stenosis).
All 10 patients with abnormal CTCA results had normal DSE. Of patients with abnormal results: one
proceeded to coronary angiography which showed non flow limiting disease and was listed for liver
transplantation; two patients with CTCA evidence of high-grade or complete LAD stenosis were
deemed too high risk for liver transplantation and not listed. 5 patients were referred to cardiology
who felt the lesions were non flow limiting and were subsequently listed for transplantation. The
remaining 2 patients are currently completing transplantation assessment. Of the 36 patients, 31% (11)
underwent liver transplantation, 36% (13) remain active on the waiting list, 28% (10) were de-listed
after work-up or died on the waiting list and 2 (5%) are currently completing assessment. No coronary
events have been observed in any CTCA patient post transplantation.
Conclusion: CTCA is a feasible study in high-risk CLD patients undergoing assessment for liver
transplantation and can give additional information beyond that provided by DSE, which in a small
number of cases affected suitability for transplantation. The precise role of CTCA in liver
transplantation assessment requires further investigation.