*2.1.3. Other causes for cardiac impairment*

Since the first transplant interventions in the 1960s, postintervention morbidity rate decreased and patient survival increased. This is due to the improvement of surgical technique and anaesthetic management as well as the emergence of new generations of immunosuppressants. Medical care of pre-transplant patients has also experienced a favourable evolution. The outcome of patients undergoing liver transplantation depends on the perioperative management. Dedicated and specialized teams for liver transplantation have a major role on the

Liver transplantation is a high-risk surgery performed on a high-risk patient, the cirrhotic patient with end-stage liver disease. The pre-anaesthetic evaluation is mandatory and plays an important role in accepting the inclusion of the patient on the transplant list. Today,

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,

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

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

• impaired contractile reserve in response to stress; this is due to a lower density of beta adrenergic receptors as well as to the negative inotropic effect of excess nitric oxide production,

Regardless of the aetiology of cirrhosis, cardiomyopathy is characterized by

patients eligible for transplant are older and often associate co-morbidities.

outcome of these patients.

**2.1. Cardiac evaluation**

diabetes and hypertension.

**2. Preoperative assessment**

210 Organ Donation and Transplantation - Current Status and Future Challenges

*2.1.1. Coronary artery disease (CAD)*

mortality risk in the cirrhotic patient [2, 4].

• increased cardiac output at baseline,

*2.1.2. Cirrhotic cardiomyopathy*

Chronic consumption of ethanol may cause dilated cardiomyopathy; it is characterized by left ventricular dilatation with altered systolic function. In the initial stages of heart disease, abstinence from alcohol can significantly improve the symptoms.

In the case of haemochromatosis, excess iron will be deposited in the myocardium, leading to restrictive cardiomyopathy [2].

#### *2.1.4. Steps of cardiac evaluation*

Investigating a patient will begin with the existence of a history of heart disease as well as symptoms suggestive of cardiovascular events such as rhythm disorders or angina. Because of their low exercise capacity due to cirrhosis, the incidence of angina is low and frequently coronary heart disease can be underestimated.

The baseline assessment includes an electrocardiographic (ECG) recording at rest and an echocardiography.

The echocardiography evaluates the following [8]:


If electrocardiogram and echocardiography are two mandatory pre-transplant investigations, the question is what other methods should be used in those patients who require additional methods.

According to AASLD (American Association for the Study of Liver Disease), AHA (American Heart Association) and ACCF (American College of Cardiology Foundation), additional investigations should be undertaken for patients who have three or more associated risk factors of the following: diabetes, left ventricular hypertrophy, history of CAD, age > 60 years, smoking, hypertension, dyslipidaemia and obesity [4, 9].

aggravated by surgery for liver transplant, the hepatopulmonary syndrome's evolution is extremely favourable post transplantation with net amelioration or even complete resolution. The cirrhotic patient might develop **pleural effusions**. The hydrothorax appears most frequently on the right side and generally accompanies ascites. It is due to an anatomical defect in the right hemidiaphragm. Sometimes, it might need drainage prior to surgery [11–13].

Anesthesia for Liver Transplantation http://dx.doi.org/10.5772/intechopen.75167 213

The cirrhotic patient may suffer from any other pulmonary disease not related to the chronic liver failure. Chronic obstructive pulmonary disease may be associated with cirrhosis, especially in smoker patients, resulting in obstructive respiratory insufficiency, which together with restrictive ascites dysfunction may greatly compromise respiratory function. Patients

Since the necessary immunosuppression after transplantation may lead to reactivation of a dormant latent tuberculosis, it is mandatory to test transplant candidates for latent tuberculosis. This is done either with the tuberculin skin test or with the quantiferon TB test, a cell

Depending on the lung's status, investigations will be limited to a chest X-ray or will go further to pulmonary ultrasound or computed tomography (CT) scan of the thorax [14, 15].

Renal dysfunction in the cirrhotic patient is due to a decreased blood volume due to vasodilation, with a decrease in glomerular filtration. It may not be reflected correctly in serum creatinine levels; the end-stage liver disease patient often has a less muscle mass and a low creatinine production. Higher sensitivity tests are cystatin C or NGAL (neutrophil gelatinase-

Two types of kidney dysfunction are related to cirrhosis: hepatorenal syndrome is type 1 with rapid deterioration in renal function (doubling serum creatinine or increasing it to >2.5 mg/dl

The occurrence of renal dysfunction can be precipitated by haemorrhage and infection [4, 16]. Preoperative renal dysfunction increases the risk of adverse development of postoperative

Coagulation abnormalities are caused by reduced concentrations of vitamin K-dependent factors and an imbalance between procoagulant and anticoagulant factors. Standard coagulation tests do not reflect rebalanced haemostasis and must not be used to predict the risk of bleeding. Procoagulant factors must not be administered unless signs of bleeding are present [17]. The Guidelines of the European Society of Anaesthesia regarding cirrhotic patients do not recommend routine preoperative correction of international normalized ratio (INR) (1.5–5) using fresh-frozen plasma but advise correction through point of care tests: rotational throm-

will be evaluated by a pneumologist for treatment and encouraged to quit smoking.

immune response assay using a *Mycobacterium tuberculosis*-like protein substrate.

**2.3. Evaluation of renal function**

in less than 2 weeks) and a type 2 with slower evolution.

boelastometry or thromboelastography [18].

associated lipocalin).

complications.

**2.4. Coagulation status**

Several types of investigations have been proposed:


Valvular dysfunctions in the cirrhotic patient on the transplant list are poorly studied. The evaluation of such a patient should include the severity of the valve dysfunction, either stenosis or regurgitation, the degree of alteration of myocardial contractility and the clinical presence of signs of insufficient cardiac output. Several cases of simultaneous liver transplantation and aortic valve replacement for tight aortic stenosis were reported in the cirrhotic patient [6].

#### **2.2. Pulmonary system**

Chronic liver disease can affect both the pleural space and the pulmonary parenchyma. The two pulmonary conditions characteristic of the cirrhotic patient are hepatopulmonary syndrome and pulmonary hypertension. The two syndromes exclude each other, and their pathophysiology depends on predominant vasodilator or vasoconstrictor elements resulting from liver dysfunction.

**Portopulmonary hypertension** is a pulmonary hypertension syndrome with vascular obstruction, coexisting with portal hypertension. The portopulmonary syndrome has important haemodynamic consequences with minor changes in blood gases.

All patients proposed for transplantation should be screened for portopulmonary hypertension as the postoperative evolution depends on it. It might be suspected in the case of a right branch block on ECG. Echocardiography can detect pulmonary hypertension and can evaluate it, but correct values are obtained by right heart catheterization. Depending on the mean pressure in the pulmonary artery (PAPm), hypertension is classified in mild (PAPm 25–34 mmHg), moderate (PAPm 35–44 mmHg) and severe (PAPm >45 mmHg).

Severe pulmonary hypertension excludes the patient from liver transplantation; moderate form may benefit from vasodilator drug treatment in pre-transplant [4]. Decision to perform liver transplant in this case depends on the response to therapy and is taken by the transplant team on an individual basis.

**Hepatopulmonary syndrome** is characterized by hypoxemia secondary to intrapulmonary shunt due to vascular dilation. In contrast with pulmonary hypertension that may be aggravated by surgery for liver transplant, the hepatopulmonary syndrome's evolution is extremely favourable post transplantation with net amelioration or even complete resolution.

The cirrhotic patient might develop **pleural effusions**. The hydrothorax appears most frequently on the right side and generally accompanies ascites. It is due to an anatomical defect in the right hemidiaphragm. Sometimes, it might need drainage prior to surgery [11–13].

The cirrhotic patient may suffer from any other pulmonary disease not related to the chronic liver failure. Chronic obstructive pulmonary disease may be associated with cirrhosis, especially in smoker patients, resulting in obstructive respiratory insufficiency, which together with restrictive ascites dysfunction may greatly compromise respiratory function. Patients will be evaluated by a pneumologist for treatment and encouraged to quit smoking.

Since the necessary immunosuppression after transplantation may lead to reactivation of a dormant latent tuberculosis, it is mandatory to test transplant candidates for latent tuberculosis. This is done either with the tuberculin skin test or with the quantiferon TB test, a cell immune response assay using a *Mycobacterium tuberculosis*-like protein substrate.

Depending on the lung's status, investigations will be limited to a chest X-ray or will go further to pulmonary ultrasound or computed tomography (CT) scan of the thorax [14, 15].
