Liver Transplantation as a Challenge for the Anesthesiologist: Preoperative Cardiac Assessment to Orient the Perioperative Period

Liver transplantation (LT) requires specific competences and relevant skills for the appropriate management of the pretransplant evaluation, particularly as regards cardiac assessment. Elderly candidates (aged well beyond 65 years old) are now very often accepted for LT, in spite of increased comorbidities and a higher cardiovascular risk, amplified by manifestations associated with a long-standing cirrhosis (the most common end-stage liver disease in LT candidates) and portal hypertension (cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary syndrome). The incidence of coronary artery disease is increasing among candidates but unfortunately no consensus exists on the stepwise paradigms to be adopted for the diagnosis and management of coronary artery disease. An appropriate cardiovascular assessment is nonetheless mandatory in LT candidates: in fact, during the LT procedure the potential candidate has to tolerate minutes (or even hours) of tachycardia, critical hypotension, severe anemia, and acidosis, conditions that only patients with a perfect cardiac status may tolerate and survive unscathed. In spite of the differences in protocols reported by different centers or countries, the most relevant “pillars” are common across the various stepwise paradigms (electrocardiography, baseline echocardiography): stress tests in high risk candidates are still relevant, but noninvasive imaging (mainly coronary computed tomography angiography) or, in the near future, new forms of stress imaging (stress cardiac magnetic resonance) will be given the appropriate and logical space in the stepwise algorithms for the LT population: the main aim of this crucial work-up is to select the right candidate for the graft, this precious and finite resource able to save and change lives.