LIVER TRANSPLANTATION 20:1277–1279, 2014

LETTER FROM THE FRONTLINE

Transcatheter Aortic Valve Implantation as Rescue Therapy for Liver Transplant Candidates With Aortic Valve Stenosis Received April 28, 2014; accepted June 21, 2014.

TO THE EDITORS: Mortality rates as high as 29% have been reported for patients with end-stage liver disease (ESLD) who undergo cardiac surgery, with postoperative liver failure, sepsis, and bleeding accounting for these rates.1 In noncardiac surgery scenarios, including liver transplantation, severe aortic stenosis carries a 31% perioperative risk of fatal and nonfatal cardiovascular events.2 Consequently, a clinical dilemma emerges in cases of concurrent aortic stenosis and ESLD because the presence of one condition limits the treatment of the other. Moreover, in cases of congestive liver disease associated with aortic valve stenosis, treatment of the valvular disease remains the only therapeutic option for effectively improving liver function. We hypothesized, therefore, that transcatheter aortic valve implantation (TAVI) could be used as a less invasive alternative treatment for patients with concomitant ESLD and high-grade aortic valve stenosis and eventually turn these patients into eligible candidates for liver transplantation. To the best of our knowledge, the use of TAVI for patients with ESLD and severe aortic valve stenosis has not been reported previously. Our objective here is to report 2 patients with ESLD who benefited from TAVI therapy. This report was approved by the Institutional Review Committee. Patient 1, a 63-year-old man with ESLD, was admitted to the emergency room with dyspnea, lung crackles, jugular distension, diffuse edema, and a systolic murmur in the aortic area. Transthoracic echocardiography showed severe aortic stenosis with maximum and mean pressure gradients of 71 and 48 mm Hg, respectively. The indexed aortic valve area was 0.55 cm2. The end-diastolic left ventricular diameter was 55 mm, and the ejection fraction was 61% (Table 1). A previous diagnosis of cirrhosis due to a chronic hepatitis C virus infection complicated by hepatocellular carcinoma was established. Because of the thrombocytopenia, a platelet count of 60,000/

mm3, and a Model for End-Stage Liver Disease score of 16 points, the patient was considered at high risk for cardiac surgery. TAVI with an Edwards SAPIEN XT system (number 26, Edwards Lifesciences, Irvine, CA) was performed. The postprocedural period was uneventful, and the symptoms of heart failure improved during the course of the following week. Antiplatelet therapy was not prescribed because of the thrombocytopenia. After 1 month, his cardiac recovery was clinically complete, and this meant that the patient was considered eligible for liver transplantation. The patient underwent orthotopic liver transplantation 6 months after TAVI. No cardiovascular complications were observed, and the patient was discharged 5 days after the procedure. Patient 2, a 77-year-old man with a past history of diabetes mellitus, systemic arterial hypertension, and coronary artery disease with previous surgical myocardial revascularization, was referred for weekly paracentesis as a result of refractory ascites. He was diagnosed with nonalcoholic steatohepatitis complicated by congestive liver disease and had a Model for End-Stage Liver Disease score of 12. During the preoperative workup for liver transplantation, transthoracic echocardiography showed severe aortic stenosis with a maximum aortic gradient of 74 mm Hg, a mean ventricular-aortic gradient of 43 mm Hg, and an aortic valve area of 0.68 cm2. The end-diastolic left ventricular diameter was 47 mm, and the left ventricular ejection fraction was 50%. The function of the right ventricle was normal. The catheterization of the left side of the heart confirmed severe aortic stenosis (Table 1). He had a serum B-type natriuretic peptide concentration of 659 pg/mL, a serum-ascites albumin gradient of 1.3, and an ascites protein concentration of 5.4 mg/dL. A transfemoral aortic valve replacement was performed with a Medtronic CoreValve system (number 29, Medtronic, Minneapolis, MN). Shortly after the procedure, the patient displayed acute atrial fibrillation and a high-grade atrioventricular blockage, and he required pacemaker implantation. Three days

~o Paulo School of Medicine, 255 Dr. Address reprint requests to Odilson Marcos Silvestre, M.D., Department of Cardiology, University of Sa ~o Paulo, Brazil 05403-000. Telephone: 155-11-30674238; Eneas de Carvalho Aguiar Avenue, Sala 9117, Sa E-mail: [email protected] DOI 10.1002/lt.23941 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases

C 2014 American Association for the Study of Liver Diseases. V

1278 LETTER FROM THE FRONTLINE

LIVER TRANSPLANTATION, October 2014

TABLE 1. Parameters Before and After TAVI Patient 1 Before Parameter Aortic valve gradient (mm Hg)* Left ventricular ejection fraction (%) Aortic valve area (cm2)

Patient 2

After Before After

TAVI

TAVI

TAVI

TAVI

70

05

70

02

61

68

50

62

0.55



0.68



*Invasive pressure gradient.

after TAVI, the echocardiographic mean aortic gradient decreased to 3 mm Hg. Platelet anti-aggregation therapy was not prescribed because of the high risk of bleeding. The patient was discharged after 12 days. After 4 weeks, there was a complete disappearance of the ascites, and there was a marked improvement in his liver biochemistry and functional capacity. Liver transplantation was not deemed necessary. We report here 2 cases of concurrent ESLD and aortic stenosis for which liver transplantation was contraindicated because of the presence of advanced aortic valve stenosis. In both cases, TAVI resulted in a marked decrease in the aortic pressure gradient. Patient 1 became eligible for and underwent liver transplantation without cardiac complications, and patient 2 had significant clinical improvement without the need for any further invasive treatment for his liver condition. As a result of the success of liver transplantation as a curative treatment for ESLD, more than 23,000 procedures were performed worldwide in 2011.3 With the spread of liver transplantation, the profile of the candidates on the waiting list has changed. Older candidates and patients with cardiovascular disease are more commonly referred, with an estimated prevalence of heart disease greater than 25%. Severe aortic stenosis in patients with ESLD has been considered a contraindication for liver transplantation because of the high risk of cardiovascular complications during the intraoperative and postoperative periods. Only patients who achieve a reduction in the ventricular-aortic pressure gradient are eligible for noncardiac surgery, including liver transplantation.2 Before the use of TAVI, different case reports suggested that the repair of cardiac valve dysfunction and liver transplantation could be performed simultaneously. Nevertheless, the applicability of conventional valve replacement surgery has been hampered by the high mortality rate.1 Balloon aortic valvotomy may be an alternative to surgery. However, complications such as acute aortic regurgitation, myocardial infarction, and strokes are common. Furthermore, 60% of treated patients develop aortic restenosis or cardiovascular mortality within the first year of follow-up.4

The advent of TAVI has made the treatment of inoperable patients possible, and TAVI is an alternative for those at high surgical risk; it has resulted in improvement in quality of life and survival rates.5 Presently, TAVI is indicated for patients with symptomatic severe aortic stenosis who are not candidates for surgical aortic valve replacement. This is due to concomitant conditions that increase the predicted mortality rate to more than 50% within 30 days after conventional surgery. Additionally, the procedure can be considered an option for patients with a high surgical risk, which is defined as a Society of Thoracic Surgeons risk score of 10% or higher. Contraindication criteria for TAVI include anatomical limitations (aortic annulus diameter), severe aortic regurgitation, stroke within the previous 6 months, and advanced chronic kidney disease. Beyond traditional risk scores, a clinical assessment by an interdisciplinary heart team and the availability of detailed imaging of the aortic valve are important factors for decision making. Since the first reported use of TAVI in 2002, experience and knowledge have improved: the procedural success rate is now approximately 95%, and the 30day mortality rate is 10%.6 These good results with TAVI have led to the expansion of its applicability to other conditions with high surgical risks. This is exemplified by patients on the waiting list for liver transplantation, who may be successfully treated with the replacement of the aortic valve. In conclusion, our report demonstrates that TAVI may be an effective and safe therapy for patients with cirrhosis and severe aortic stenosis. Odilson Marcos Silvestre, M.D.1 Fernando Bacal, M.D.1 Danusa Souza Ramos, R.N.2 Flavio Tarasoutchi, M.D.1 Tarso D. Acorsi, M.D.1 bio Fernandes, M.D.1 Fa Pedro A. Lemos, M.D.1  Carrilho, M.D.2 Flair Jose Luiz A. C. D’Albuquerque, M.D.2 Alberto Queiroz Farias, M.D.2 1 Departments of Cardiology and 2Gastroenterology ~ o Paulo School of Medicine University of Sa ~ o Paulo, Brazil Sa

REFERENCES 1. Thielmann M, Mechmet A, Neuh€ auser M, Wendt D, Tossios P, Canbay A, et al. Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery. Eur J Cardiothorac Surg 2010;38:592-599. 2. Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F, et al. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med 2004;116:8-13. 3. Global Observatory on Donation and Transplantation. Organ Donation and Transplantation Activities 2011. http://www.transplant-observatory.org/pages/Data-Reports.aspx. Accessed December 2013.

LIVER TRANSPLANTATION, Vol. 20, No. 10, 2014

4. Lieberman EB, Bashore TM, Hermiller JB, Wilson JS, Pieper KS, Keeler GP, et al. Balloon aortic valvuloplasty in adults: failure of procedure to improve longterm survival. J Am Coll Cardiol 1995;26:1522-1528. 5. Makkar RR, Fontana GP, Jilaihawi H, Kapadia S, Pichard AD, Douglas PS, et al.; for PARTNER Trial Investigators.

LETTER FROM THE FRONTLINE 1279

Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012;366:1696-1704. 6. G en ereux P, Head SJ, Wood DA, Kodali SK, Williams MR, Paradis JM, et al. Transcatheter aortic valve implantation 10-year anniversary: review of current evidence and clinical implications. Eur Heart J 2012;33:2388-2398.

Transcatheter aortic valve implantation as rescue therapy for liver transplant candidates with aortic valve stenosis.

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