Restoring liver transplant candidacy with transcatheter aortic valve implantation in a patient with cirrhosis and severe aortic stenosis

The convergence of severe aortic stenosis and end-stage liver disease in orthotopic liver transplantation (OLT) candidates is an increasingly recognized clinical challenge, driven by the shared cardiometabolic risk factor profile underpinning both metabolic dysfunctionassociated steatotic liver disease (MASLD) and degenerative valvular disease. Severe aortic stenosis constitutes a contraindication to OLT due to the hemodynamic burden it imposes perioperatively, while advanced cirrhosis frequently precludes conventional surgical aortic valve replacement (SAVR). In patients with advanced cirrhosis, cardiac surgery may carry a prohibitive risk owing to coagulopathy, immune dysfunction, poor nutritional status, renal impairment, and the severity of liver disease and its complications. The 2024 EASL Clinical Practice Guidelines on liver transplantation and the 2025 International Liver Transplantation Society and the Liver Intensive Care Group of Europe guidelines for cardiovascular assessment before liver transplantation explicitly mandate structured preoperative risk stratification, including the treatment of significant structural heart disease, as part of the pre-transplant workup [1,2]. Transcatheter aortic valve implantation (TAVI) has emerged as the solution to this therapeutic impasse. We report a case in which TAVI was used as a bridge to successfully restore OLT eligibility.A 63-year-old male with hypertension, dyslipidemia, type 2 diabetes mellitus, former smoking (30 pack-years), and chronic alcohol misuse presented in March 2023 with acute pulmonary oedema (APE) and type 2 myocardial infarction due to acute anemia from large esophageal varices, managed by endoscopic band ligation. He also had a history of STelevation myocardial infarction in 2013, treated with percutaneous revascularization of the circumflex artery, and, in accordance with both current and contemporary recommendations, was receiving indefinite aspirin therapy [3]. The workup confirmed mixed-etiology (alcoholic and MASLD-related) cirrhosis with portal hypertension, right portal vein thrombosis, and hepatocellular carcinoma (HCC) within up-to-seven criteria. Coronary angiography confirmed patency of the previously stented artery. Transthoracic echocardiography demonstrated severe aortic stenosis (peak gradient 66 mmHg, mean gradient 43 mmHg, valve area 0,52 cm2/m2) with left ventricular systolic function at the lower limit of normal (left ventricular ejection fraction [LVEF] by the biplane Simpson's method 55%). Two episodes of grade II hepatic encephalopathy occurred during the same admission. The patient was deemed ineligible for surgical aortic valve replacement owing to prohibitive perioperative morbidity and mortality in the setting of decompensated cirrhosis .In October 2024, TAVI was performed under local anesthesia with conscious sedation. The procedure was uneventful and hemodynamically well tolerated, with no clinically significant bleeding related to coagulopathy or portal hypertension and no new conduction disturbances. After full recovery, the patient was referred to complete the pretransplant work-up, including repeat computed tomography, which confirmed that the HCC remained within the up-to-seven criteria. Once preserved left ventricular systolic function (LVEF 60%) and normal function of the bioprosthetic aortic valve (mean gradient 9 mmHg) were confirmed, the case was reviewed by the liver transplant committee, and the patient was listed for OLT in April 2025.In August 2025, OLT was performed uneventfully from a cardiac perspective. Intraoperative monitoring included electrocardiography, invasive arterial pressure, and central venous pressure. Aspirin 100 mg was maintained throughout the perioperative period. Postoperative complications included hepatic artery thrombosis requiring reexploration, thrombectomy, and splenic artery ligation; and caecal perforation with polymicrobial peritonitis (Streptococcus sanguinis and Bacteroides thetaiotaomicron), treated surgically. No cardiac complications were documented, and echocardiography at discharge confirmed preserved LVEF and a normally functioning bioprosthetic valve. At fourteen months of follow-up, the patient remains asymptomatic in NYHA class I, with no readmissions, and serial echocardiograms confirm durable prosthesis function (Figure 1). This case illustrates an increasingly prevalent scenario: an OLT candidate with significant structural heart disease in the setting of shared cardiometabolic risk factors. TAVI is a viable treatment option for severe aortic stenosis in patients across different stages of liver disease, with careful and individualized patient selection [4]. Compared with surgical aortic valve replacement (SAVR), TAVI appears to be associated with a shorter length of hospital stay, lower healthcare costs, fewer complications, and lower short-term mortality [5]. However, long-term data on TAVI outcomes in patients with cirrhosis are limited. As a bridge to OLT specifically, Levy et al. reported three patients with cirrhosis who regained transplant eligibility after TAVI [6], and Caughron et al. found that 7 of 29 patients with end-stage liver or renal disease undergoing TAVI were subsequently listed for transplantation [7]. In addition, the safety of major abdominal surgery after TAVI has been documented across all post-procedural time intervals [10]. Careful patient selection, guided by the severity of liver disease and renal impairment, is critical to avoid futile interventions [8]. Regarding the continuation of antithrombotic therapy, American and European guidelines recommend maintaining low-dose aspirin in patients with prior percutaneous coronary intervention undergoing non-cardiac surgery [9,10]. This strategy appeared to be acceptable in our experience. These observations suggest that TAVI may be considered a means of restoring OLT candidacy in highly selected patients with cirrhosis, provided that a coordinated multidisciplinary approach is applied. Given the limited evidence, further studies are needed to confirm these findings and define the appropriate candidates.