Liver Transplant Advice

[Angus Avagadro]

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Patient being evaluated for liver transplant at a major transplant center. Their MELD score is over 30. They passed all the requirements to be presented to the transplant committee. Although the nuclear stress test was normal and they have no cardiac history, a cardiac cath was performed. It revealed
RT heart dominance
LAD 60 % diffuse dx with multiple discrete lesions
CX 60% distal discrete dx
Om2 50% diffuse dx
EF nl
No cardiac sx ever, even with End Stage Liver Dx.
The Dr told patient that they would need by pass surgery and might be too risky to transplant.
My question is
Most carsiologists would not consider stenting them with mild/moderate stenosis. Are they too high risk for transplant or are they trying to protect their statistics?
My opinion is that a competent anesthesiologist who has experience with liver transplants should get them through surgery, but immunosuppressive therapy may worsen their CAD and might need to be addressed at a later date. Thanks in advance for your input.

 

[vector2]

I have a family member being evaluated for liver transplant at a major transplant center. Their MELD score is over 30. They passed all the requirements to be presented to the transplant committee. Although the nuclear stress test was normal and they have no cardiac history, a cardiac cath was performed. It revealed
RT heart dominance
LAD 60 % diffuse dx with multiple discrete lesions
CX 60% distal discrete dx
Om2 50% diffuse dx
EF nl
No cardiac sx ever, even with End Stage Liver Dx.
The Dr told my family member that they would need by pass surgery and might be too risky to transplant.
My question is
Most carsiologists would not consider stenting them with mild/moderate stenosis. Are they too high risk for transplant or are they trying to protect their statistics?
My opinion is that a competent anesthesiologist who has experience with liver transplants should get them through surgery, but immunosuppressive therapy may worsen their CAD and might need to be addressed at a later date. Thanks in advance for your input.

It's unfortunate they got sent for a cath with no cardiac hx and a negative nuclear stress.

Further, I think there are some guidelines which recommend revascularization for LM disease or LM-equivalent with >50% stenosis before liver transplant, but I don't think those are really that evidenced-based.

" A recent report has shown that the application of an aggressive revascularization paradigm may significantly improve the outcomes of patients with CAD undergoing LT. In this study of 630 patients who received LT, 151 (24%) had > 50% stenosis on CA (defined as obstructive CAD). In total 80 patients underwent coronary intervention prior to LT (9 with moderate and 71 with severe disease), 2 had angioplasty, 46 stenting, and 32 CABG (5 combined with LT). There was no significant difference in 1‐year survival in patients with >50% stenosis and the 1‐year survival in patients with and without obstructive CAD was 84% and 86%, respectively.83 "

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One question I have: was iFR/FFR done by the interventional cardiologist during the cath? The lesions may have been hemodynamically significant even if they weren't visually significant.

 

[kidthor]

Where I trained they would still transplant them. Also unclear why they got cathed with a normal stress test.

Probably not a good idea to stent that because of the need for aspirin and plavix post - plus then you’re in a tight spot down the line If you need to give platelets during liver tx (which is often).

 

[Angus Avagadro]

It's unfortunate they got sent for a cath with no cardiac hx and a negative nuclear stress.

View attachment 320585


Further, I think there are some guidelines which recommend revascularization for LM disease or LM-equivalent with >50% stenosis before liver transplant, but I don't think those are really that evidenced-based.

" A recent report has shown that the application of an aggressive revascularization paradigm may significantly improve the outcomes of patients with CAD undergoing LT. In this study of 630 patients who received LT, 151 (24%) had > 50% stenosis on CA (defined as obstructive CAD). In total 80 patients underwent coronary intervention prior to LT (9 with moderate and 71 with severe disease), 2 had angioplasty, 46 stenting, and 32 CABG (5 combined with LT). There was no significant difference in 1‐year survival in patients with >50% stenosis and the 1‐year survival in patients with and without obstructive CAD was 84% and 86%, respectively.83 "

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One question I have: was iFR/FFR done by the interventional cardiologist during the cath? The lesions may have been hemodynamically significant even if they weren't visually significant.

IFR LAD 0.58 ruled abnormal
IFR OM2 0.89 ruled borderline

 

[vector2]

IFR LAD 0.58 ruled abnormal
IFR OM2 0.89 ruled borderline

While the ship has sailed regarding whether they should've gotten the cath in the first place, an argument can be made that revascularization may be in their best interest. BMS PCI of the LAD + 30 days of DAPT and leaving the CX/OM alone given the borderline lesions and right dominance would be nice, but PCI might not be possible given the diffuse dx and multiple lesions.

However, if the CABG needs to be done I would recommend off-pump since you can potentially avoid a lot of the problems associated with CPB and ESLD.

In either case, if they don't have a bunch of other comorbidities and their functional status is good then I don't think they're prohibitively high risk for either cardiac surgery or OLT.

 

[MoMoGesiologist]

Anyone got good data to show periop CABG/stenting reduces risk MACE for primary surgery?

Based on what you are describing, these coronary findings seem incidental and now causing more issues and introducing more risk without improving outcomes

 

[Angus Avagadro]

While the ship has sailed regarding whether they should've gotten the cath in the first place, an argument can be made that revascularization may be in their best interest. BMS PCI of the LAD + 30 days of DAPT and leaving the CX/OM alone given the borderline lesions and right dominance would be nice, but PCI might not be possible given the diffuse dx and multiple lesions.

However, if the CABG needs to be done I would recommend off-pump since you can potentially avoid a lot of the problems associated with CPB and ESLD.

In either case, if they don't have a bunch of other comorbidities and their functional status is good then I don't think they're prohibitively high risk for either cardiac surgery or OLT.

I was thinking the diffuse LAD may not me amenable to to percutaneous intervention, but I didn't see the cath. Only co morbidity is NASH. They were given a biologic by their Rheumatologist and that seems to be the final straw leading to ESLD. I am flying down to discuss this with their doctors. If they can show it is not in my family members best interest to transplant, I will live with it. If I get the sense they are protecting their statistics, I will announce at the end of the meeting I am going for a haircut and for them to watch the local evening news as I will be on it. I can't thank you enough for the expert input and references. You have tempered my initial thoughts on this as my personal experience is somewhat dated. I'll try to let everyone know how this eventually plays out. Thanks again!

 

[vector2]

Anyone got good data to show periop CABG/stenting reduces risk MACE for primary surgery?

No. But the institution and the liver committee might not care now that there's already a cath with iFR proven LAD dz.

I was thinking the diffuse LAD may not me amenable to to percutaneous intervention, but I didn't see the cath. Only co morbidity is NASH. They were given a biologic by their Rheumatologist and that seems to be the final straw leading to ESLD. I am flying down to discuss this with their doctors. If they can show it is not in my family members best interest to transplant, I will live with it. If I get the sense they are protecting their statistics, I will announce at the end of the meeting I am going for a haircut and for them to watch the local evening news as I will be on it. I can't thank you enough for the expert input and references. You have tempered my initial thoughts on this as my personal experience is somewhat dated. I'll try to let everyone know how this eventually plays out. Thanks again!

I would make sure that IC, CT surgery, and the liver team have really had a frank discussion with each other before anyone on the liver team starts laying down proclamations about your family member being too high risk. The fact that functional status is good, there is no angina, there is no LM disease, there is no 3VD, and EF is normal all argue in favor of proceeding with OLT even without revascularization.

 

[Urzuz]

I would make sure that IC, CT surgery, and the liver team have really had a frank discussion with each other before anyone on the liver team starts laying down proclamations about your family member being too high risk. The fact that functional status is good, there is no angina, there is no LM disease, there is no 3VD, and EF is normal all argue in favor of proceeding with OLT even without revascularization.

By the sound of the OP, the "doctor" (I assume from the transplant service?) drew their own conclusions from the cath report.

Has your family member actually spoken to a cardiologist/CT surgery team? Depending on which team (CT surgery, cardiology, transplant) has the most clout and quite frankly the most aggressive personalities, this discussion could go a number of different ways (CT surgery or cards says that they are fine for OLT and urges transplant surgery into proceeding, transplant refuses to touch the patient and bullies cardiology/CT surg to revascularize the patient first, etc).

As has been said, it's unfortunate that an unnecessary test was ordered that now muddies the water as to how to proceed.

 

[Hork Bajir]

I’m at an academic center, and in my previous attending life I did a fair number of high risk (MELD > 35) liver transplants. I would do this case. Is it higher risk because of the CAD? Probably. Does addressing the CAD first decrease the risk? I’m not aware of any evidence to suggest that is the case (always open to learn tho). My gut feeling is that the risk of PCI vs CAB plus the risk of in stent thrombosis in the peri op period is higher than the risk of NSTEMI (or god forbid plaque rupture) during OLTx.

Also gotta remember that cath doesn’t tell the whole story. Especially in someone who is asymptomatic... How sure are we that there aren’t collaterals past the stenoses? Myocardial O2 consumption is gonna be high in ESLD- every day is a stress test.

 

[Iso4ane]

If her liver disease is at bad as it sounds, she’s probably already hyper dynamic and has a cardiac output that’s through the roof. If doesn’t have a problem now...

 

[GassYous]

I would probably do the case with a tee and an intro but wouldn't want any kind of cardiac revasc. So far our evidence shows no difference in outcome whether or not you do cabg or pci preop for high risk surgery although in a different patient population.

Without access to the chart in a patient I don't know, I won't comment on their specific workup. But I think the workups we do in general are pretty unnecessary for most patients and most cases.

https://www.nejm.org/doi/full/10.1056/NEJMoa041905

 

[Angus Avagadro]

I’m at an academic center, and in my previous attending life I did a fair number of high risk (MELD > 35) liver transplants. I would do this case. Is it higher risk because of the CAD? Probably. Does addressing the CAD first decrease the risk? I’m not aware of any evidence to suggest that is the case (always open to learn tho). My gut feeling is that the risk of PCI vs CAB plus the risk of in stent thrombosis in the peri op period is higher than the risk of NSTEMI (or god forbid plaque rupture) during OLTx.

Also gotta remember that cath doesn’t tell the whole story. Especially in someone who is asymptomatic... How sure are we that there aren’t collaterals past the stenoses? Myocardial O2 consumption is gonna be high in ESLD- every day is a stress test.

I actually presented a paper at an international symposium of liver transplantation many years ago looking at risk stratification. We could not identify discrete risk factors and concluded the hemodynamics of ESLD screend out people with significant cad. However, NASH was not much of a thing back then either, so there is that. The paper @Vector provided reports some interesting data on this very topic.

 

[bigdan]

We would do this case.

Could consider asking for POBA at time of listing; we use only ASA after angioplasty. Then you’d have (presumably) excellent TIMI flow/normal iFR documented. It feels stupid suggesting that in an asymptomatic person...

If the Txp service won’t budge, you might consider seeking listing at another center, if geographically feasible.

Good luck, and kudos for fighting for what you think is right.

 

[WheezyBaby]

I took care of an ESLD transplant work up with a floridly abnormal stress who then got stented and had a catastrophic GIB shortly following. The idea of stenting an asymptomatic patient and delaying their transplant a time frame in which they could likely die not accounting for the increased risk related to bleeding after stenting feels wrong. But hey I'm not an anesthesiologist

 

[epidural man]

To OP: Disclosure - I didn't read your post, nor the what is likely great answers to your post.

What I did read was the title of the thread "Liver Transplant Advice"

Here is my advice reagarding any anesthesia for liver transplants. Don't work at a place that does them. How's that for great advice?

 

[dchz]

@Angus Avagadro , Echoing @bigdan , props to you for doing the best thing you can for your family. I was recently in a similar situation with my father and i'm not sure I would be as cool headed you to ask for consensus from experts, kudos. I will present my perspective on the matter:

Before med school I did data entry research for liver transplants for months. I also sat in on the weekly liver transplant listing meetings numerous times. I've personally provided anesthesia for 30+ liver transplants and many many more CABGs. I have also sat in on the weekly cardiology conferences during fellowship and I've seen a lot of caths. These experiences give me just enough knowledge to be dangerous, but not enough to see the entire picture. E.g. I have never followed up on my liver transplant pts after more than 2 weeks post op nor have I followed up on my CABG pts for more than 2 weeks post op. I may not know what I don't know so take my perspective with a grain of salt.

Liver transplant surgery and immediate recovery: it should not be a big deal given the right surgeon and anesthesiologist. The skill level of liver transplant surgeons vary greatly, even within the same group. The #1 thing you can do to lower mortality for your family member is trying to find the best surgeon possible. You don't want the surgeon that screams at you about the CVP when the pt has 3+ TR, all the while taking 20 mins to control one bleeding vein. You want the guy that is a cool cat that can sew the anastomosis when there is bomb going off. The CAD with no symptoms and normal heart is not a major road block in execution of the anesthestic. I would encourage you to get a place with good dedicated intensivists. That's really easily said than done. I'm not sure i've been at an institution where I would feel entirely comfortable with the intensivists on staff. Going to an institution that does >100 liver transplants per year also helps a lot, the experience of ICU staff also matters a lot in post op recovery.

Transplant listing: I was pretty naive before med school, but i don't remember one time a doctor did not fight for their patient during a transplant listing. You're right, their incentives are not 100% aligned, they are incentivized to protect their numbers. However, I cannot remember one time where the patient's doctor didn't do everything in their power to get their patients the best shot at long term quality of life. I also wonder if may be we are missing some crucial information here. Is the patient being considered compliant? was there some other history being left out? If they come back with this consensus, there must be more to the picture than mod CAD. You might be right, may be this is brand new transplant program. But I would try to read in between the lines and etc. Sometimes they see it as risk mitigation - if a noncompliant patient is compliant enough to get through CABG and cardiac rehab, he is much lower risk to this limited resource of a liver.

Couple of other things to consider:
-Several metroplexes can be gamed to double list in two different UNOS regions. I'm not sure if this is still true, but back in the day Dallas was one region while Ft Worth was a different UNOS region. Meaning a patient living in the metroplex could be listed in two regions at the same time. The NE also has several UNOS regions that can provide similar situations.
-I would not burn any bridges. I would HIGHLY recommend NOT going on TV to denounce a liver transplant program. Not only does this separate your concentration into a lot unproductive efforts. It will taint your loved one's ability to get listed elsewhere.
-Being there for your loved one also provides a great amount of comfort and support. Take the time to explain how the process goes. Given them some insight to what's going on behind the scenes, how the surgery and recovery process goes, etc. Just taking the time to explain the minutia with your loved one can mean a world to them.
- Balloon angioplasty suggested by @bigdan is a great alternative/compromise to CABG. Highly worth a try.

 

[Angus Avagadro]

@Angus Avagadro , Echoing @bigdan , props to you for doing the best thing you can for your family. I was recently in a similar situation with my father and i'm not sure I would be as cool headed you to ask for consensus from experts, kudos. I will present my perspective on the matter:

Before med school I did data entry research for liver transplants for months. I also sat in on the weekly liver transplant listing meetings numerous times. I've personally provided anesthesia for 30+ liver transplants and many many more CABGs. I have also sat in on the weekly cardiology conferences during fellowship and I've seen a lot of caths. These experiences give me just enough knowledge to be dangerous, but not enough to see the entire picture. E.g. I have never followed up on my liver transplant pts after more than 2 weeks post op nor have I followed up on my CABG pts for more than 2 weeks post op. I may not know what I don't know so take my perspective with a grain of salt.

Liver transplant surgery and immediate recovery: it should not be a big deal given the right surgeon and anesthesiologist. The skill level of liver transplant surgeons vary greatly, even within the same group. The #1 thing you can do to lower mortality for your family member is trying to find the best surgeon possible. You don't want the surgeon that screams at you about the CVP when the pt has 3+ TR, all the while taking 20 mins to control one bleeding vein. You want the guy that is a cool cat that can sew the anastomosis when there is bomb going off. The CAD with no symptoms and normal heart is not a major road block in execution of the anesthestic. I would encourage you to get a place with good dedicated intensivists. That's really easily said than done. I'm not sure i've been at an institution where I would feel entirely comfortable with the intensivists on staff. Going to an institution that does >100 liver transplants per year also helps a lot, the experience of ICU staff also matters a lot in post op recovery.

Transplant listing: I was pretty naive before med school, but i don't remember one time a doctor did not fight for their patient during a transplant listing. You're right, their incentives are not 100% aligned, they are incentivized to protect their numbers. However, I cannot remember one time where the patient's doctor didn't do everything in their power to get their patients the best shot at long time quality of life. I also wonder if may be we are missing some crucial information here. Is the patient being considered compliant? was there some other history being left out? If they come back with this consensus, there must be more to the picture than mod CAD. You might be right, may be this is brand new transplant program. But I would try to read in between the lines and etc. Sometimes they see it as risk mitigation - if a noncompliant patient is compliant enough to get through CABG and cardiac rehab, he is much lower risk to this limited resource of a liver.

Couple of other things to consider:
-Several metroplexes can be gamed to double list in two different UNOS regions. I'm not sure if this is still true, but back in the day Dallas was one region while Ft Worth was a different UNOS region. Meaning a patient living in the metroplex could be listed in two regions at the same time. The NE also has several UNOS regions that can provide similar situations.
-I would not burn any bridges. I would HIGHLY recommend NOT going on TV to denounce a liver transplant program. Not only does this separate your concentration into a lot unproductive efforts. It will taint your loved one's ability to get listed elsewhere.
-Being there for your loved one also provides a great amount of comfort and support. Take the time to explain how the process goes. Given them some insight to what's going on behind the scenes, how the surgery and recovery process goes, etc. Just taking the time to explain the minutia with your loved one can mean a world to them.
- Balloon angioplasty suggested by @bigdan is a great alternative/compromise to CABG. Highly worth a try.

I think angioplasty makes good sense. I am not sure if his LAD is a long segmental lesion and might not be amenable to angioplasty. Then maybe an off pump LIMA might be an option. Making it sound like they will not survive surgery with moderate CAD worries me. He would most likely would be treated medically if he were not having a liver transplant. The institution has excellent statistics. It just makes me wonder if they are attempting to perform yield protection for their stats. I will press them on some of these issues on Mon.

 

[dchz]

The institution has excellent statistics. It just makes me wonder if they are attempting to perform yield protection for their stats. I will press them on some of these issues on Mon.

What is their volume?

Also I forgot to mention, have you considered living donor transplant? There are centers around the country that do them and I've personally done both the donor anesthesia and recipient anesthesia. It's overall a much better operation mortality wise.

 

[Angus Avagadro]

What is their volume?

Also I forgot to mention, have you considered living donor transplant? There are centers around the country that do them and I've personally done both the donor anesthesia and recipient anesthesia. It's overall a much better operation mortality wise.

They did around 160 deceased donors last year. No living related. I'm not sure living related has better1 yr survival stats and it puts 2 people at risk. I dont think living related donor with a MELD score of 30+ is viable at this point as the donor has to be cleared and clean living for 3 months. This is my understanding. I totally agree with the right surgeon and anesthesiologist. I haven't wrapped my arms around this high risk status cardiac status they claim. As I mentioned earlier, they probably would not offer PCI if they were not on the transplant list. They would just treat his CAD medically. They have significant joint issues which reduce mobility, but non smoker and no other cardio pulm or renal issues. They are also only a few years from the age cutoff for transplant. This is why I think they did the cath to look for a reason to say no. This is my clearly biased opinion.

 

[dchz]

They did around 160 deceased donors last year. No living related. I'm not sure living related has better1 yr survival stats and it puts 2 people at risk. I dont think living related donor with a MELD score of 30+ is viable at this point as the donor has to be cleared and clean living for 3 months. This is my understanding. I totally agree with the right surgeon and anesthesiologist. I haven't wrapped my arms around this high risk status cardiac status they claim. As I mentioned earlier, they probably would not offer PCI if they were not on the transplant list. They would just treat his CAD medically. They have significant joint issues which reduce mobility, but non smoker and no other cardio pulm or renal issues. They are also only a few years from the age cutoff for transplant. This is why I think they did the cath to look for a reason to say no. This is my clearly biased opinion.

160 is a solid center. I'm not sure the policy on the living donor. I have no meta data right now, but I am certain that living donor has way better 1 year survival based on my own follow up data alone. A lot of people qualifies as "clean living" even without any lifestyle modifications. If you can't get to a place that offers it though, it wouldn't matter to you anyways.

How significant is the joint issue? What is the Pt's BMI? ADLs?

I think most people agreed that the CAD as you described isn't a big deal. But let us know what you end up reading in between the lines on monday. Good luck sir.

 

[Angus Avagadro]

160 is a solid center. I'm not sure the policy on the living donor. I have no meta data right now, but I am certain that living donor has way better 1 year survival based on my own follow up data alone. A lot of people qualifies as "clean living" even without any lifestyle modifications. If you can't get to a place that offers it though, it wouldn't matter to you anyways.

How significant is the joint issue? What is the Pt's BMI? ADLs?

I think most people agreed that the CAD as you described isn't a big deal. But let us know what you end up reading in between the lines on monday. Good luck sir.

Thank you. To answer your question, BMI 35 and was fully functional at home prior to worsening of their condition. Was considering knee replacement due to DJD and limiting activitie, but was driving, grocery shoppong, climbing stairs, etc.

 

[Gastrapathy]

Tried to PM you but you restrict that.

 

[Angus Avagadro]

Update:
I sparred with a hepatologist at the transplant center today. They presented some odd findings. They claim they have had 3 patients die on the table as a result of intraventricular clotting after reperfusion. Evidently NASH is a different creature and the byproducts of reperfusion injury in these patients seem to promote clotting, not in the coronaries, but intraventricular. I have participated in about 100 liver transplants many years ago. Never had anything like that happen. In fairness, NASH wasn't very prevalent many years ago either. Anybody able to corroborate this?. I don't think they will list my family member, and have reached out to another regional center. They use EPIC and can see the workup to date. If they don't get listed, the other center can probably present them next week.

 

[Hork Bajir]

intracardiac thrombus is a rare but obviously catastrophic complication of OLT. I’ve personally seen it twice: one L sided thrombus that died, and one R sided clot that survived (gave 20,000 units heparin, tho the literature seems to suggest that these clots will resolve at the same rate with and without heparin). Based on the lit review that I’ve done, the risk for IC thrombosis is more to do with the degree of coagulation system disturbance than with the etiology of liver failure, NASH or otherwise. If a pt comes with the OR with a high MELD and compensated/sub clinical DIC, the bleeding and massive transfusion can tip them over the edge into full blown DIC with all of its attendant complications.

Have to say that I’m a little bit lost as to what any of this has to do with the coronary disease? And even if there is a higher risk of IC thrombus with NASH, so what? It’s still a rare event- is this center just going to stop transplanting NASH patients? Something about this story doesn’t add up.

 

[Angus Avagadro]

intracardiac thrombus is a rare but obviously catastrophic complication of OLT. I’ve personally seen it twice: one L sided thrombus that died, and one R sided clot that survived (gave 20,000 units heparin, tho the literature seems to suggest that these clots will resolve at the same rate with and without heparin). Based on the lit review that I’ve done, the risk for IC thrombosis is more to do with the degree of coagulation system disturbance than with the etiology of liver failure, NASH or otherwise. If a pt comes with the OR with a high MELD and compensated/sub clinical DIC, the bleeding and massive transfusion can tip them over the edge into full blown DIC with all of its attendant complications.

Have to say that I’m a little bit lost as to what any of this has to do with the coronary disease? And even if there is a higher risk of IC thrombus with NASH, so what? It’s still a rare event- is this center just going to stop transplanting NASH patients? Something about this story doesn’t add up.

I think they just dont want to list them. I agree with you, it doesnt add up. My personal view is that it's yield protection for their statistics. Maybe they have more complications to date than normal and dont want do anyone that might carry higher than normal risk. IDK.
Thank you very much for your insight. I only had one operative death, and that was a patient I met on wide open levophed in full rejection for a redo. Never had a patient with a ventricular thrombus or heard of one in probably 600 cases at our institution. Thanks again.

 

[vector2]

I think they just dont want to list them. I agree with you, it doesnt add up. My personal view is that it's yield protection for their statistics. Maybe they have more complications to date than normal and dont want do anyone that might carry higher than normal risk. IDK.
Thank you very much for your insight. I only had one operative death, and that was a patient I met on wide open levophed in full rejection for a redo. Never had a patient with a ventricular thrombus or heard of one in probably 600 cases at our institution. Thanks again.

One of my colleagues had an intraop RA/RV thrombus during OLT when I was a resident. They actually gave low dose tpa, clot resolved, and luckily the pt didn’t bleed to death.

But you and the poster above are right. There is something not adding up. Try to get listed elsewhere.

 

[Angus Avagadro]

UPDATE:
Actually spoke with the periop team yesterday. Apparently hepatologist was giving me all complications, not just related to their CAD. Anesthesia was not terribly concerned about an intra op event and felt their risk of MACE was more in the several months following transplant. This confirms my opinion and what several small studies have reported. They will stent LAD tomorrow, and cardiology has agreed to reduce dual platelet therapy from 90 to 30 days before listing them. This will be a close one as their MELD score is around 40. The 90 day mortality with that score is around 70% I'll update everyone as things progress. Thanks to all for your assistance.

 

[WheezyBaby]

UPDATE:
Actually spoke with the periop team yesterday. Apparently hepatologist was giving me all complications, not just related to their CAD. Anesthesia was not terribly concerned about an intra op event and felt their risk of MACE was more in the several months following transplant. This confirms my opinion and what several small studies have reported. They will stent LAD tomorrow, and cardiology has agreed to reduce dual platelet therapy from 90 to 30 days before listing them. This will be a close one as their MELD score is around 40. The 90 day mortality with that score is around 70% I'll update everyone as things progress. Thanks to all for your assistance.

Glad to hear. For my knowledge, I'm still a bit confused why they wouldn't delay PCI to post-transplant, maybe you or someone else can clarify that

 

[Angus Avagadro]

Glad to hear. For my knowledge, I'm still a bit confused why they wouldn't delay PCI to post-transplant, maybe you or someone else can clarify that

This is a small study I found suggesting PCI prior to LT reduces risk to LT without CAD. This is the centers thought process . If link doesnt open,its

Satapathy, in Transplantation 2017;101:793-803

 

[abolt18]

UPDATE:
Actually spoke with the periop team yesterday. Apparently hepatologist was giving me all complications, not just related to their CAD. Anesthesia was not terribly concerned about an intra op event and felt their risk of MACE was more in the several months following transplant. This confirms my opinion and what several small studies have reported. They will stent LAD tomorrow, and cardiology has agreed to reduce dual platelet therapy from 90 to 30 days before listing them. This will be a close one as their MELD score is around 40. The 90 day mortality with that score is around 70% I'll update everyone as things progress. Thanks to all for your assistance.

I hope the contrast from the procedure doesn't worsen renal function.

 

[Angus Avagadro]

I hope the contrast from the procedure doesn't worsen renal function.

Nephrologist was confident the CRRT would remove the contrast rather quickly. Interestingly, they say the kidneys are dormant right now and if transplanted soon, should recover fully. The longer it takes to transplant, the greater the risk of KI. They arent all that concerned about his kidneys strangely, just plan on transplanting a kidney too if necessary. I somehow dont think it will be that easy.

 

[Hork Bajir]

Sorry you and your family are going through this, it really sucks. To me it seems that this is probably your relative’s window to get a txp, and the increased risk of delaying it will more than outweigh the decrease in risk from PCI... But what do I know, I’m just a simple country anesthesiologist 😵😵

 

[Angus Avagadro]

Sorry you and your family are going through this, it really sucks. To me it seems that this is probably your relative’s window to get a txp, and the increased risk of delaying it will more than outweigh the decrease in risk from PCI... But what do I know, I’m just a simple country anesthesiologist 😵😵

My gut tells me the same. One study basically said the one year survival was anout 8 % less than the usual LT patient. I pointed this out and agreed the risk without PCI was higher but not prohibitive. I also suggested PCI after LT but was shot down by cardiology. Surgery wont proceed without cardio's blessing. So the 30 day countdown begins. Thanks for you concern and your input.