A subclinical high tricuspid regurgitation pressure gradient independent of the mean pulmonary artery pressure is a risk factor for the survival after living donor liver transplantation

Abstract

BackgroundPortopulmonary hypertension (POPH) is characterized by pulmonary vasoconstriction, while hepatopulmonary syndrome (HPS) is characterized by vasodilation. Definite POPH is a risk factor for the survival after orthotopic liver transplantation (OLT), as the congestive pressure affects the grafted liver, while subclinical pulmonary hypertension (PH) has been acknowledged as a non-risk factor for deceased donor OLT. Given that PH measurement requires cardiac catheterization, the tricuspid regurgitation pressure gradient (TRPG) measured by echocardiography is used to screen for PH and congestive pressure to the liver. We investigated the impact of a subclinical high TRPG on the survival of small grafted living donor liver transplantation (LDLT).MethodsWe retrospectively analyzed 84 LDLT candidates. Patients exhibiting a TRPG ≥25 mmHg on echocardiography were categorized as potentially having liver congestion (subclinical high TRPG; n = 34). The mean pulmonary artery pressure (mPAP) measured after general anesthesia with FIO20.6 (mPAP-FIO20.6) was also assessed. Patients exhibiting pO2 < 80 mmHg and an alveolar-arterial oxygen gradient (AaDO2) ≥ 15 mmHg were categorized as potentially having HPS (subclinical HPS; n = 29). The clinical course after LDLT was investigated according to subclinical high TRPG.ResultsA subclinical high TRPG (p = 0.012) and older donor age (p = 0.008) were correlated with a poor 40-month survival. Although a higher mPAP-FIO20.6 was expected to correlate with a worse survival, a high mPAP-FIO20.6 with a low TRPG was associated with high frequency complicating subclinical HPS and a good survival, suggesting a reduction in the PH pressure via pulmonary shunt.ConclusionIn cirrhosis patients, mPAP-FIO20.6 may not accurately reflect the congestive pressure to the liver, as the pressure might escape via pulmonary shunt. A subclinical high TRPG is an important marker for predicting a worse survival after LDLT, possibly reflecting congestive pressure to the grafted small liver.

Clinical impact of mild to moderate pulmonary hypertension in living‐donor liver transplantation

“…However, many studies showed that echocardiography performs poorly in detecting patients with mild to moderate PHT [19][20][21][22]. A subclinical high-pressure gradient of tricuspid regurgitation was also reported to be an important marker for predicting worse survival after LDLT [16,23]. Our present study demonstrated that the maximal velocity of tricuspid regurgitation significantly correlated with mean pulmonary artery pressure, but the predictive power of PHT was not satisfactory.…”

Intraoperative anesthetic management of the liver transplant recipient with portopulmonary hypertension

“…Portopulmonary hypertension (POPH) is defined as pulmonary artery hypertension associated with portal hypertension, and is a serious complication of cirrhosis. POPH occurs in about 5-10% of liver transplantation recipients and is associated with poor prognosis [1,2]. Female sex and autoimmune hepatitis are associated with an increased risk of POPH, whereas patients with hepatitis C infection have a lower risk [3 && ,4 ,5,6].…”

A Case of Severe Tricuspid Valve Regurgitation in a Patient Undergoing Orthotopic Liver Transplantation: Whether to Proceed, or Not

“…This may reflect the inability of the right ventricle to accommodate the increased central blood volume. Likewise, another retrospective analysis of 84 living donor liver transplant recipients demonstrated that subclinical elevated TR pressure gradient (≥25 mmHg) was strongly associated with decreased three-month and one-year survival post-liver transplant [16].…”