This study attempts to evaluate the efficacy of dobutamine stress echocardiography for preoperative cardiac risk stratification in patients undergoing orthotopic liver transplantation. Two hundred twenty consecutively submitted patients were evaluated in preparation for orthotopic liver transplantation. Dobutamine stress echocardiography was performed in 80 patients with known or suspected coronary artery disease. Follow-up information was available in 40 patients in the form of cardiac catheterization and/or outcome from liver transplantation to validate the dobutamine stress echo findings. The prevalence of coronary artery disease in this cohort was 5% and was closely associated with the presence of diabetes mellitus. Dobutamine stress echocardiography, when interpreted as abnormal in the presence of wall motion abnormalities only, is associated with a sensitivity, specificity, and positive and negative predictive value of 100%. Dobutamine stress echocardiography is highly efficacious and should be the screening study of choice to detect coronary artery disease in patients undergoing orthotopic liver transplantation. Copyright 1998 by the American Association for the Study of Liver DiseasesO rthotopic liver transplantation (OLT) in patients with coronary artery disease (CAD) is associated with significant morbidity and mortality. 1 Carey et al 2 found that 27% of patients older than 50 years who underwent evaluation for OLT had moderate to severe CAD; the CAD was clinically unsuspected in 13.3% of those with CAD. 3 Furthermore, they identified diabetes mellitus (DM) as an independent risk factor. Despite these data, the ideal preoperative cardiac screening study in patients with end-stage liver disease (ESLD) has yet to be determined. Studies have shown that dobutamine stress echocardiography (DSE) is an accepted technique for the evaluation of CAD in general, 3,4 and more specifically before major vascular surgery 5,6 and kidney transplantation. 7 Donovan et al 8 have shown that the absence of inducible ischemia by DSE confers low risk for myocardial infarction during OLT; however, the inclusion criteria for their study were broad and included many low-risk patients. We therefore sought to evaluate the efficacy of DSE in identifying significant cardiac risk before OLT in the subgroup of patients with a history of and/or significant risk factors for CAD. Materials and MethodsPatient evaluations and decisions regarding cardiac workup were made prospectively; however, the data were analyzed in a retrospective fashion.Two hundred twenty consecutive patients were evaluated for OLT. Careful attention was paid to symptoms of cardiac ischemia and/or risk factors for CAD during the initial evaluation. DSE was performed in 80 patients based on the following criteria: age greater than 50 years but less than 60 with two or more cardiac risk factors (tobacco use, obesity, hypercholesterolemia, hypertension, family history); age greater than than 60 years; presence of active symptoms indicative of CAD; electrocardiographic...

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Chronic epoprostenol, in conjunction with a multidisciplinary, well-planned perioperative evaluation and treatment plan, may be the answer to a heretofore untreatable disease.

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