Liver Transplantation in Patients With Atrial Fibrillation J. Bargehr, J.F. Trejo-Gutierrez, B.G. Rosser, T. Patel, M.L. Yataco, S. Pungpapong, C.B. Taner, and J. Aranda-Michel ABSTRACT In this study we described survival and incidence of perioperative and postoperative complications in liver transplant recipients with known atrial fibrillation. A total number of 717 patients underwent liver transplantation between January 2005 and December 2008 at our institution. In this population, preoperative paroxysmal or chronic-persistent atrial fibrillation was diagnosed in 32 patients (4.5%). Of these, 12 patients died during follow-up and 4 patients required liver retransplantation. Perioperative cardiac complications occurred in 10 patients (31%) resulting in 3 cardiac-related deaths. Median patient survival was 1613 days (range, 22e2492) and median graft survival was 1524 days (range, 10e2492). Twenty patients are still alive with a median survival of 1861 days (range, 1189e2492) after liver transplantation. L IVER transplantation (LT) is a life-saving procedure for treating patients with end-stage liver disease. As a result of refined surgical technique, improved perioperative care, and advances in immunosuppression over the past two decades, its efficacy and safety have increased. The success of LT has subsequently increased the demand to consider older patients with various comorbidities for LT. However, the practice of LT is limited by the disparity between organ availability and the number of candidates on the wait list. Therefore, transplantation programs are required to frequently re-evaluate their selection criteria. While infection and rejection have been reported as major causes of death in the early postoperative period, 1,2 cardiovascular disease is a leading cause of death in the long-term, along with new onset of malignancy and recurrence of primary disease. 3e5 Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF increases the risk of heart failure and stroke substantially and is associated with increased mortality. 6e8 However, the prevalence of AF and its impact in patients undergoing LT have not yet been described. This study describes our experience in patients with preoperative AF who underwent LT at our institution. PATIENTS AND METHODS This retrospective study comprises all patients who underwent LT at our institution between January 2005 and December 2008. This study was reviewed and approved by our Institutional Review Board. Follow-up was complete as of June 2012. Patients with AF diagnosed on the basis of electrocardiograms (ECG) available up to two years before the date of LT were iden- tified and reviewed. Patients with new onset of AF after LT were excluded. AF was defined according to the 2011 update of the American College of Cardiology/American Heart Association/ European Society of Cardiology (ACC/AHA/ESC) 2006 Guidelines for the Management of Patients With Atrial Fibrillation. 9 This definition classifies AF as recurrent if a patient has more than one episode, as paroxysmal if termination occurs within 7 days, and as chronic-persistent if present beyond 7 days. Recipient information included demographic data, calculated Model for End-stage Liver Disease (MELD) score at the time of LT, patient survival days, graft survival days, and cardiac and noncardiac complications after LT. History of smoking, alcohol abuse, diabetes mellitus, hypertension, obesity, dyslipidemia, and coronary artery disease were recorded and the type of cardiovas- cular drugs administered before LT were reviewed. For classifica- tion of obesity, dyslipidemia, and metabolic syndrome, World Health Organization (WHO) criteria were used. 10 Pre-LT cardiac variables were gathered retrospectively using ECG, transthoracic echocardiography (TTE), dobutamine stress echocar- diogram (DSE), and saline contrast echocardiogram. Type of AF (recurrent, paroxysmal, or chronic-persistent), left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), right ventricular systolic pressure (RVSP), left atrial size (LAS), left atrial volume (LAV), presence and degree of tricuspid and mitral valve regurgitation, and size of the ventricular septum, presence of myo- cardial ischemia, left ventricular ejection fraction (EF) at rest, and presence of intracardiac or intrapulmonary shunts were recorded. Patient survival was defined as the time elapsed from LT to patient death. Graft survival was defined as the time elapsed from LT to From the Departments of Transplantation, and Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, Florida, USA. Address reprint requests to C. Burcin Taner, MD, Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224. E-mail: taner.burcin@mayo.edu 0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.02.130 ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 2302 Transplantation Proceedings, 45, 2302e2306 (2013)