The Use of TAVR as a Bridge for Liver and Kidney Transplant

Case Study By Gaurav Dhar, MBBS, FSCAI, FACC, Sushant Koirala, MD, and Laith A. Derbas, MD

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Case Study By Gaurav Dhar, MBBS, FSCAI, FACC, Sushant Koirala, MD, and Laith A. Derbas, MD

Introduction

Severe aortic stenosis (AS) poses a clinical dilemma in liver cirrhosis patients who are being evaluated for transplant surgery. Traditionally, liver cirrhosis was a relative contraindication for surgical aortic valve replacement (SAVR), and severe aortic stenosis was a relative contraindication for liver transplant.

The PARTNER 1 trial evaluated transcatheter aortic valve replacement (TAVR) in high-risk patients including those with liver disease, but it excluded patients with liver cirrhosis and those planning to undergo transplant.(3-5) We present a case of a patient with severe aortic stenosis, liver cirrhosis and end-stage renal disease who underwent a TAVR procedure as a bridge to liver and kidney transplant.

History

A 71-year-old male has a pertinent past medical history of nonalcoholic fatty liver disease (NAFLD), cirrhosis complicated by esophageal and rectal varices and hepatic encephalopathy, and coronary artery disease (CAD).

Presentation and Examination

As part of routine transplant evaluation, TTE revealed the presence of severe aortic stenosis (mean gradient 47 mmHg, peak velocity 4.1 m/s, and estimated valve area of 0.9 cm²) and a coronary angiogram showed mild to moderate nonobstructive CAD with 50% distal left anterior descending (LAD).

The patient's course was complicated by severe anemia and thrombocytopenia secondary to liver disease. The patient was evaluated by cardiovascular surgery; however, he was deemed to be at a very high risk to undergo SAVR (STS score 8.2%). Following a heart team approach, the decision was made to proceed with TAVR first followed by transplant surgery.

Treatment

The patient was transferred to the cardiac ICU for further optimization prior to TAVR. He then successfully underwent a TAVR procedure with a 29 mm S3 Edwards Resilia valve carried out via right transfemoral approach without any complications.

After the procedure, TTE showed a normally functioning aortic valve bioprosthesis with a mean gradient of 6 mmHg, peak velocity of 1.72 m/s, and an aortic valve area of 3.15 cm². The rest of the patient’s hospital course was relatively unremarkable and was further optimized from a volume status with large volume paracentesis with 3.6 L removed and aggressive diuresis.

In the interim between his TAVR and transplant surgery, the patient had repeat hospitalizations related to worsening liver function and subsequently developed kidney function due to hepatorenal syndrome requiring initiation of hemodialysis. Ultimately, the patient received a simultaneous liver and kidney transplant three months after the TAVR procedure. The patient tolerated the surgery well without complications.

Discussion

Prior to TAVR, liver transplantation in a patient with severe aortic stenosis posed a clinical challenge to physicians due to increased systemic and splanchnic vasodilation in the setting of a fixed obstruction. Furthermore, coagulopathies caused by liver cirrhosis makes it harder to fully optimize a patient prior to cardiac surgery and increases risk of severe bleeding.

The advent of TAVRs has enabled physicians to offer a treatment option for these high-risk patients given its minimally invasive nature and lower risk of hemodynamic compromise.

Like cirrhosis, end-stage renal disease (ESRD) also presents with a series of problems that put patients at a higher risk of intraprocedural and postprocedural complications, including further platelet dysfunction and vascular complication.(13)

Our case demonstrates that TAVR can be carried out safely in these vulnerable patients and serves as a bridge to receive dual organ transplant.

Conclusion

TAVR is a viable alternative to SAVR, especially in patients deemed too high-risk for surgery. Although the original PARTNER trial looked at high-risk patients with liver disease being one of the qualifying criteria, the trial does not specifically address cirrhotic patients who present with a whole host of complications that prevent surgery, such as coagulopathies, pancytopenia and hemodynamic instability. As seen in our case, a TAVR can serve as a useful bridge to both liver and kidney transplant.  

References

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Meet the Author

Gaurav Dhar, MD

Gaurav Dhar, MD

Interventional Cardiology, Cardiovascular Disease Make an Appointment