Clinical predictors of pulmonary hypertension in patients undergoing liver transplant evaluation

Abstract

Clinical prediction of portopulmonary hypertension (PPHTN) is critical in the preoperative evaluation of candidates for orthotopic liver transplantation (OLT) because of its association with significant morbidity and mortality. To determine the clinical, laboratory, and echocardiographic predictors of PPHTN, we retrospectively evaluated 55 candidates before OLT. From those, 8 candidates had pulmonary hypertension ([HTN] group A) and 47 candidates did not (group B). Pulmonary HTN was defined as a mean pulmonary artery pressure (PAP) of 25 mm Hg or greater and either elevated pulmonary vascular resistance or normal pulmonary artery wedge pressure. The significant predictors of PPHTN were (1) systemic arterial HTN (63% in group A v 9% in group B; P <.001), (2) loud pulmonary component of the second heart sound (38% v 2%; P =. 001), (3) right ventricular (RV) heave (38% v 4%; P =.002), (4) RV dilatation by echocardiogram (63% v 0%; P <.001), (5) RV hypertrophy by echocardiogram (38% v 0%; P =.001), and (6) echocardiogram-estimated systolic PAP (SPAP) greater than 40 mm Hg (63% v 2%; P <.001). The sensitivity of these variables for the detection of pulmonary HTN ranges from 37% to 63%, and their specificity from 91% to 100%. We conclude that several clinical and echocardiographic features are significantly associated with pulmonary HTN in patients with cirrhosis. In particular, echocardiogram-estimated SPAP greater than 40 mm Hg is strongly associated with pulmonary HTN and is specific. These predictors, however, are not sensitive enough to identify all the patients with PPHTN. Therefore, the evaluation of a combination of these variables may be useful for the preoperative identification of pulmonary HTN in liver transplant candidates.

Diagnosis of portopulmonary hypertension in candidates for liver transplantation: A prospective study

“…Based on the previous results of studies comparing preoperative and peroperative investigations, it has been suggested that, even if not specific, Doppler echocardiography when performed at evaluation is a reliable tool for detecting pulmonary hypertension. 5,6,10 An important finding in this study is that no significant correlation was found between preoperative and peroperative values of MPAP when measured by catheterization in patients who had or did not have portopulmonary hypertension. In contrast to what could be expected, MPAP was on average higher during the first phase of transplantation (under general anesthesia and before incision) than at evaluation in patients without portopulmonary hypertension.…”

“…3 Because portopulmonary hypertension is frequently asymptomatic until mean pulmonary pressure exceeds 40 mm Hg, most authors recommend systematic screening at evaluation. Several studies have suggested that Doppler echocardiography, when performed during pretransplantation evaluation, is a useful noninvasive tool to document or exclude portopulmonary hypertension, [4][5][6] even though this technique carries a significant proportion of false positives. 5,6 However, in these studies, the results of Doppler echocardiography at the time of pretransplantation evaluation have been compared with those of catheterization at the time of surgery.…”

“…Several studies have suggested that Doppler echocardiography, when performed during pretransplantation evaluation, is a useful noninvasive tool to document or exclude portopulmonary hypertension, [4][5][6] even though this technique carries a significant proportion of false positives. 5,6 However, in these studies, the results of Doppler echocardiography at the time of pretransplantation evaluation have been compared with those of catheterization at the time of surgery. It is likely that comparing different techniques used at different time points, either with or without general anesthesia, generates significant bias.…”

Utility of Echocardiography Versus BNP Level for the Prediction of Pulmonary Arterial Pressure in Patients With Pulmonary Arterial Hypertension

“…20,21) The sensitivity and specificity of TTE or a diagnosis of PAH ranges from 0.79-1.0 and 0.60-0.98, respectively. 22) At our institution, we assign a value of 10 mmHg for RAP within the Bernoulli principle formula (PAP-TTE = TR-PG + RAP). However, even when assigning this value, TTE still overestimated PAP.…”

Evaluation respiratory function of lungs and structure-functions parameters right of heart and blood floow disorders in pulmonary artery in confront with Doppler portal haemodynamics in patients with a liver cirrhosis

“…При корреляци онном анализе выявлено, что степень выраженности одышки нарастала с утяжелением цирроза (r = 0,27; р = 0,01). Несмотря на то, что одышка, обнаружен ная при опросе больных, не является патогномонич ным симптомом при ЛАГ, тем не менее при физичес ких нагрузках это наиболее частый признак дебюта данного заболевания [18,20]. В связи с этим была проведена оценка одышки по шкале MRC у больных ЦП с наличием и отсутствием ЛАГ, результаты кото рой показали, что среди больных ЦП с признаками ЛАГ одышка была более выраженной (III-IV степе ни) в сравнении с пациентами без ЛАГ (I-II степе ни), что утяжеляет течение основного заболевания (р = 0,03).…”