1
|
Martinez-Perez S, McCluskey SA, Davierwala PM, Kalra S, Nguyen E, Bhat M, Borosz C, Luzzi C, Jaeckel E, Neethling E. Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions. J Cardiothorac Vasc Anesth 2024; 38:1015-1030. [PMID: 38185566 DOI: 10.1053/j.jvca.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024]
Abstract
Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.
Collapse
Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre Toronto, General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sanjog Kalra
- Division of Cardiology, Interventional Cardiology Section, Peter Munk Cardiac Center Toronto General Hospital, University Health Network and Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elsie Nguyen
- Department of Medical Imaging, Cardiothoracic Imaging Division Lead, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Gastroenterology, Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Borosz
- Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Carla Luzzi
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Department of Gastroenterology, Ajmera Transplant Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Elmari Neethling
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
Martinez-Perez S, Davierwala P, McCluskey SA, Kalra S, Luzzi C, McGilvray I, Kalogeropoulos G, Bhat M, Neethling E. Hybrid Coronary Artery Revascularization Before Liver Transplantation: A Case Report. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00465-2. [PMID: 37516596 DOI: 10.1053/j.jvca.2023.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Piroze Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sanjog Kalra
- Department of Cardiology, Interventional Cardiology, Toronto General Hospital, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Carla Luzzi
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian McGilvray
- Department of General Surgery, Hepatobiliary Division, Toronto General Hospital, University of Toronto University Health Network, Toronto, Ontario, Canada
| | - Gregory Kalogeropoulos
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Gastroenterology, Hepatology, Toronto General Hospital, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Elmari Neethling
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
3
|
Neethling E, Heggie JE. Considerations in Critical Care and Anesthetic Management of Adult Patients Living with Fontan Circulation. Can J Cardiol 2022; 38:1100-1110. [PMID: 35490923 DOI: 10.1016/j.cjca.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/02/2022] Open
Abstract
The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia (TA), pulmonary atresia (PA), hypoplastic left heart syndrome (HLHS), and double inlet left ventricle (DILV), all of which involve a functional single-ventricle physiology. The complexity of the patients' original anatomy combined with the anatomical and physiological consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for non-cardiac surgery, peripartum management for labor and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplant, and advanced mechanical support. This review focuses on the anesthetic and ICU management of these patients during their perioperative journey, with an emphasis on the continuity of pre-intervention planning, referral pathways, and post-intervention intensive care unit (ICU) management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiological reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atrio- pulmonary (AP) Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to their situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.
Collapse
Affiliation(s)
| | - Jane E Heggie
- Toronto General Hospital, University Health Network, Toronto.
| |
Collapse
|
4
|
Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
|
5
|
Ortner CM, Macias P, Neethling E, Krishnamoorthy V, Carvalho B, Swanevelder JL, Dyer RA. Ocular sonography in pre-eclampsia: a simple technique to detect raised intracranial pressure? Int J Obstet Anesth 2019; 41:1-6. [PMID: 31704252 DOI: 10.1016/j.ijoa.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/07/2019] [Accepted: 09/08/2019] [Indexed: 11/16/2022]
Affiliation(s)
- C M Ortner
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, CA, USA; Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
| | - P Macias
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, CA, USA
| | - E Neethling
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada
| | | | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, CA, USA
| | - J L Swanevelder
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - R A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| |
Collapse
|
6
|
Ortner CM, Krishnamoorthy V, Neethling E, Flint M, Swanevelder JL, Lombard C, Fawcus S, Dyer RA. Point-of-Care Ultrasound Abnormalities in Late-Onset Severe Preeclampsia: Prevalence and Association With Serum Albumin and Brain Natriuretic Peptide. Anesth Analg 2019; 128:1208-1216. [PMID: 31094790 DOI: 10.1213/ane.0000000000003759] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pilot studies applying point-of-care ultrasound (POCUS) in preeclampsia indicate the presence of pulmonary interstitial edema, cerebral edema, and cardiac dysfunction. Laboratory markers of oncotic pressure (albumin) and cardiac dysfunction (brain natriuretic peptide [BNP]) may be abnormal, but the clinical application remains unclear. We investigated the prevalence of pulmonary interstitial syndrome (PIS), cardiac dysfunction, and increased optic nerve sheath diameter (ONSD) in late-onset preeclampsia with severe features. The primary aim was to examine the association between PIS or ONSD and maternal serum albumin level. The secondary aims were to explore the association between cardiac dysfunction and PIS, ONSD, BNP, and serum albumin level and between POCUS-derived parameters and a suspicious or pathological cardiotocograph. METHODS Ninety-five women were enrolled in this prospective observational cohort study. A POCUS examination of lungs, heart, and ONSD was performed. PIS was defined as a bilateral B-line pattern on lung ultrasound and diastolic dysfunction according to an algorithm of the American Society of Echocardiography. ONSD >5.8 mm was interpreted as compatible with raised intracranial pressure (>20 mm Hg). Serum BNP and albumin levels were also measured. RESULTS PIS, diastolic dysfunction, systolic dysfunction, and raised left ventricular end-diastolic pressure (LVEDP) were present in 23 (24%), 31 (33%), 9 (10%), and 20 (25%) women, respectively. ONSD was increased in 27 (28%) women. Concerning the primary outcome, there was no association between albumin level and PIS (P = .4) or ONSD (P = .63). With respect to secondary outcomes, there was no association between albumin level and systolic dysfunction (P = .21) or raised LVEDP (P = .44). PIS was associated with diastolic dysfunction (P = .02) and raised LVEDP (P = .009; negative predictive value, 85%). BNP level was associated with systolic (P < .001) and diastolic dysfunction (P = .003) and LVEDP (P = .007). No association was found between POCUS abnormalities and a suspicious/pathological cardiotocograph (P = .07). CONCLUSIONS PIS, diastolic dysfunction, and increased ONSD were common in preeclampsia with severe features. Cardiac ultrasound abnormalities may be more useful than albumin levels in predicting PIS. The absence of PIS may exclude raised LVEDP. The further clinical relevance of PIS and raised ONSD remains to be established. BNP level was associated with cardiac ultrasound abnormalities. Although this study was not designed to directly influence clinical management, the findings suggest that POCUS may serve as a useful adjunct to clinical examination for the obstetric anesthesiologist managing these complex patients.
Collapse
Affiliation(s)
- Clemens M Ortner
- From the Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Elmari Neethling
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Margot Flint
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Justiaan L Swanevelder
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, Western Cape, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Susan Fawcus
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| |
Collapse
|
7
|
Bavaresco L, Lemaignen J, Neethling E, Squeri C, Coulon-Leroy C. Influence of pedoclimatic factors on grapevine performance and berry ripening: Preliminary results of Chardonnay grown in Friuli Venezia Giulia region, Italy. BIO Web Conf 2019. [DOI: 10.1051/bioconf/20191501010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The concept of terroir is widely used in the wine industry, and many studies are undertaken to better understand the influence of local terrain features on produced wines. In this context, this study monitored nine Chardonnay plots in the Fruili wine region of Italy to gather information on grapevine growth and berry ripening. The study objective was to define viticulture potentialities allowing to identify future strategies for the production of a “single vineyard” Chardonnay wine at the Vie di Romans estate, Italy. During the growing season of 2017, relations were studied between terrain features and field observations on vine phenology and grape ripening. Stem water potential and gas exchange measurements were also effectuated. Results show that there are significant differences between the studied plots. Earliness of the grapevine cycle between the plots has been less evident to determine than the variation in berry characteristics. The latter were linked with identified pedoclimatic units, but the effect of the cultural practices should not be overlooked. The study should be perceived as a first monitoring campaign, highlighting the important differences between study plots. Further investigation in the following seasons should give a more accurate perception of individual plot characteristics and their impacts.
Collapse
|