Liver transplantation (LT) offers a cure for Australians with end-stage liver disease. Cardiovascular (CV) disease remains a leading cause of death following LT, with rates of post-transplant cardiac events remaining high over the past 20 years despite improvements in overall complication rates. This may be due to undetected cardiac dysfunction, termed cirrhotic cardiomyopathy (CCM), however our ability to diagnose and treat this condition in clinical practice remains limited. Using a novel, validated method for identifying this condition using stress testing, we aim to evaluate whether CCM increases the risk of post-transplant CV events, and determine whether LT leads to a reversal of this condition.
Studies have also demonstrated that dysfunction of the endothelium in the small blood vessels, termed microvascular dysfunction, is a precursor to atherosclerosis and is associated with organ failure and increased mortality in cirrhosis. It has also been demonstrated to be an early predictor of future cardiac events, renal dysfunction and heart failure in non-cirrhotic populations. Importantly, these changes appear to be dynamic and may improve with changes in the patient’s physiology. The dynamic vessel analyser (DVA) uses a retinal camera and flicker-light induced nitric oxide release to provide a rapid and non-invasive assessment of a patient’s microvascular function. We aim to use this tool to determine whether microvascular dysfunction is associated with an increased risk of CCM or CV events in LT patients, and whether this finding is reversible following LT.
In summary, we propose the use of two novel non-invasive risk assessment tools, an impaired cardiac reserve on stress testing and an assessment of retinal microvascular dysfunction, that have the potential to augment point-of-care discussions about the risk of post-transplant cardiac events. Based on the outcome of this proposal, the long-term goal is to assess whether use of early therapeutic interventions in patients with cirrhotic cardiomyopathy can mitigate the risk of post-transplant cardiovascular events.