Liver transplant outcome of cirrhotic patients treated with coronary stenting and early discontinuation of dual antiplatelet therapy

Background Significant coronary artery disease (CAD) should be treated with percutaneous revascularization in pre-liver transplant (LT) work-up. New-generation drug-eluting stents (DES) allow early discontinuation of dual antiplatelet therapy (DAPT). We aimed to describe pre-LT management and early post-LT outcome of our patients with CAD who underwent Percutaneous Coronary Intervention (PCI). Methods We enrolled all patients transplanted in our Centre from 01/2018 to 04/2022 who underwent pre-LT cardiac catheterization (CATH). Stenosis ≥50% in a major-vessel or stenosis ≥70% in a moderate-sized branch vessel indicated significant CAD. Results Among 638 adult patients who received LT, 33 underwent pre-LT CATH (5%) due to previous history of obstructive CAD (18%), positive noninvasive stress-test (61%), inconclusive noninvasive test (15%) or CAD symptoms (6%). CATH showed normal coronaries in 6/33 (18%), non-obstructive CAD in 15/33 (46%) and significant CAD in 12/33 (36%). These 12 patients were all male, median age 64 years, 75% diabetics, 83% smokers, median BMI 26kg/m2 and underwent PCI with single (6/12) or ≥ 2 coronary arteries stenting (6/12). Patients received 31 days (IQR 31-41) of DAPT (clopidogrel+cardioaspirin), followed by aspirin monotherapy; anemia was a concern, without pre-LT major bleeding. Registration on the LT waiting list and LT occurred after 14 days (7-87) and 77 days (12-172) respectively from DAPT discontinuation. The median number of red blood cell units transfused during LT was 5 (2-7). At the end of LT, median arterial lactate and noradrenaline requirement were 1.9 mmol/L and 0.13 γ/Kg/min (Table 1). After a median follow-up of 321 days from LT: patient #1 experienced acute heart failure at month 4th (EF 35%), following major gastrointestinal bleeding (hemoglobin 4.2 g/dL); CATH was unchanged; patient improved with blood transfusion (EF at discharge 45%). Conclusion Coronary DES revascularization and early clopidogrel discontinuation was safe in cirrhotic patients with significant CAD and allowed timely LT. Significant coronary artery disease (CAD) should be treated with percutaneous revascularization in pre-liver transplant (LT) work-up. New-generation drug-eluting stents (DES) allow early discontinuation of dual antiplatelet therapy (DAPT). We aimed to describe pre-LT management and early post-LT outcome of our patients with CAD who underwent Percutaneous Coronary Intervention (PCI). We enrolled all patients transplanted in our Centre from 01/2018 to 04/2022 who underwent pre-LT cardiac catheterization (CATH). Stenosis ≥50% in a major-vessel or stenosis ≥70% in a moderate-sized branch vessel indicated significant CAD. Among 638 adult patients who received LT, 33 underwent pre-LT CATH (5%) due to previous history of obstructive CAD (18%), positive noninvasive stress-test (61%), inconclusive noninvasive test (15%) or CAD symptoms (6%). CATH showed normal coronaries in 6/33 (18%), non-obstructive CAD in 15/33 (46%) and significant CAD in 12/33 (36%). These 12 patients were all male, median age 64 years, 75% diabetics, 83% smokers, median BMI 26kg/m2 and underwent PCI with single (6/12) or ≥ 2 coronary arteries stenting (6/12). Patients received 31 days (IQR 31-41) of DAPT (clopidogrel+cardioaspirin), followed by aspirin monotherapy; anemia was a concern, without pre-LT major bleeding. Registration on the LT waiting list and LT occurred after 14 days (7-87) and 77 days (12-172) respectively from DAPT discontinuation. The median number of red blood cell units transfused during LT was 5 (2-7). At the end of LT, median arterial lactate and noradrenaline requirement were 1.9 mmol/L and 0.13 γ/Kg/min (Table 1). After a median follow-up of 321 days from LT: patient #1 experienced acute heart failure at month 4th (EF 35%), following major gastrointestinal bleeding (hemoglobin 4.2 g/dL); CATH was unchanged; patient improved with blood transfusion (EF at discharge 45%). Coronary DES revascularization and early clopidogrel discontinuation was safe in cirrhotic patients with significant CAD and allowed timely LT.