**2.1. Cardiac evaluation**

#### *2.1.1. Coronary artery disease (CAD)*

The cirrhotic patient has long been considered to be protected from coronary artery disease (CAD) due to his/her haemodynamic profile associated to a low serum cholesterol level. However, recent studies show that CAD has the same prevalence in this group compared to the general population. Patients frequently associate risk factors for CAD such as obesity, diabetes and hypertension.

The incidence of CAD does not seem to be influenced by the aetiology of cirrhosis except for non-alcoholic steatohepatitis (NASH), in which case it is twice as high, NASH associating with the metabolic syndrome [1]. The importance of CAD detection is due to the haemodynamic high stress during liver transplant leading to exacerbation of the cardiac suffering during surgery or generating postoperative cardiac complications [2, 3]. Recognizing CAD is very important, but the best therapeutic approach in case of significant coronary stenosis is not well defined.

Coronary angioplasty may be recommended, but due to the need for heavy anti-aggregation, this may increase the risk of bleeding in the cirrhotic patient. When required, bare metal stents are preferred to pharmacologically active ones because of a shorter period of anti-aggregation. Surgical intervention for myocardial revascularization is not recommended due to a very high mortality risk in the cirrhotic patient [2, 4].

#### *2.1.2. Cirrhotic cardiomyopathy*

Cirrhotic patients have myocardial dysfunction secondary to hepatic impairment [5].

Regardless of the aetiology of cirrhosis, cardiomyopathy is characterized by


The prolonged QT interval is associated with the severity of liver disease and the degree of portal hypertension as well as mortality [2]. A QTc interval of >440 ms correlates with an increased risk of ventricular arrhythmias [7].

Both diastolic and systolic dysfunction can be causes of postoperative pulmonary oedema. Right heart dysfunction, when present, has a higher predictive value for postoperative cardiac complications.
