Hepatic vein arrival time as assessed by contrast-enhanced ultrasonography is useful for the assessment of portal hypertension in compensated cirrhosis

Abstract

The measurement of the hepatic venous pressure gradient (HVPG) for the estimation of portal hypertension (PH) in cirrhosis has some limitations, including its invasiveness. Hepatic vein arrival time (HVAT), as assessed by microbubble contrast-enhanced ultrasonography (CEUS), is negatively correlated with the histological grade of liver fibrosis because of the associated hemodynamic abnormalities. Anatomical and pathophysiological changes in liver microcirculation are the initial events leading to PH. However, the direct relationship between HVAT and PH has not been evaluated. The present study measured both HVPG and HVAT in 71 consecutive patients with compensated cirrhosis and analyzed the relationship between the two parameters (i.e., the derivation set). Results were validated in 35 compensated patients with cirrhosis at another medical center (i.e., the validation set). The derivation set had HVPG and HVAT values of 11.4 6 5.0 mmHg (mean 6 standard deviation; range, 2-23) and 14.1 6 3.4 seconds (range, 8.4-24.2), respectively; there was a statistically significant negative correlation between HVPG and HVAT (r 2 5 0.545; P < 0.001). The area under the receiver operating characteristic curve (AUROC) was 0.973 for clinically significant PH (CSPH; HVPG, !10 mmHg), and the sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios for CSPH for an HVAT cut-off value of 14 seconds were 92.7%, 86.7%, 90.5%, 89.7%, 6.95, and 0.08, respectively. In addition, a shorter HVAT was associated with worse Child-Pugh score (P < 0.001) and esophageal varices (P 5 0.018). In the validation set, there was also a significant negative correlation between HVAT and HVPG (r 2 5 0.538; P < 0.001), and AUROC 5 0.953 for CSPH. HVAT was significantly correlated with PH. These results indicate that measuring HVAT is useful for the noninvasive prediction of CSPH in patients with compensated cirrhosis. (HEPATOLOGY 2012;56:1053-1062 P ortal hypertension (PH) leads to serious complications, such as variceal bleeding, and is responsible for significant morbidity and mortality in patients with cirrhosis.1 In compensated cirrhosis in particular, the presence of clinically significant PH (CSPH) makes it possible to predict a poor prognosis, such as progression to decompensated cirrhosis or mortality. 2 This makes the precise grading of PH Abbreviations: AUROC, area under ROC curve; CEUS, contrast-enhanced ultrasonography; 95% CI, 95% confidence interval; CSPH, clinically significant

Evolving therapies for liver fibrosis

“…The hepatic vein pressure gradient (HVPG) is an excellent predictor of decompensation or death in patients with cirrhosis (126). A non-invasive alternative, the hepatic vein arrival time of an injected ultrasound contrast agent, needs further validation (127).…”

The Accuracy of Ultrasonography for the Evaluation of Portal Hypertension in Patients with Cirrhosis: A Systematic Review

“…The average age of the patients was 53.2 ± 9.6 years old. Only two studies (8, 32) included more than 100 patients.…”

“…This parameter reflects disease severity and has a strong prognostic value with regard to survival and decompensation in patients with compensated cirrhosis (6). However, the widespread routine clinical use of this method has been limited by the procedure's invasive nature and the requirements for skilled expertise and special equipment (7, 8). …”

Diagnostic imaging modalities

“…Bolus injections of microbubble agents can be used for first-pass kinetics studies, and can be used to assess transit times. It has been shown that hepatic vein transit times shorten when the liver disease worsens [33,37,38]. In theory, shorter hepatic vein transit times in patients with diffuse liver disease occur mainly secondary to arteriovenous shunting and arterializations of capillary beds in the liver and, to a lesser degree, shunting in the pulmonary and gastrointestinal capillaries.…”