Inducible Left Ventricular Outflow Tract Gradient During Dobutamine Stress Echocardiography: An Association with Intraoperative Hypotension But Not a Contraindication to Liver Transplantation

Maraj, Suraj; Jacobs, Larry E.; Maraj, Rajiv; Contreras, Rafael; Rerkpattanapipat, Pairoj; Malik, Taseem A.; Manzarbeitia, Cosme; Muñoz, Santiago J.; Rothstein, Kenneth D.; Kotler, Morris N.

doi:10.1111/j.0742-2822.2004.03068.x

Cited by 41 publications

(21 citation statements)

References 21 publications

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“…Left ventricular hypertrophy and hyperdynamic systolic function in ESLD may result in hemodynamically significant LVOTO. One retrospective review of 106 transplant recipients found inducible LVOTO on pre-operative DSE in Ͼ40% of patients (69). In this study, an outflow gradient of Ͼ36 mm Hg was significantly associated with intraoperative hypotension.…”

Section: Pre-operative Cardiovascular Assessment and Managementmentioning

confidence: 48%

Cardiovascular Risk Assessment of the Liver Transplant Candidate

Raval

Harinstein

Skaro

et al. 2011

Journal of the American College of Cardiology

229

174

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Liver transplantation (LT) candidates today are increasingly older, have greater medical acuity, and have more cardiovascular comorbidities than ever before. Steadily rising model for end-stage liver disease (MELD) scores at the time of transplant, resulting from high organ demand, reflect the escalating risk profiles of LT candidates. In addition to advanced age and the presence of comorbidities, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Patients with cirrhosis requiring LT usually demonstrate increased cardiac output and a compromised ventricular response to stress, a condition termed cirrhotic cardiomyopathy. These cardiac disturbances are likely mediated by decreased beta-agonist transduction, increased circulating inflammatory mediators with cardiodepressant properties, and repolarization changes. Low systemic vascular resistance and bradycardia are also commonly seen in cirrhosis and can be aggravated by beta-blocker use. These physiologic changes all contribute to the potential for cardiovascular complications, particularly with the altered hemodynamic stresses that LT patients face in the immediate post-operative period. Post-transplant reperfusion may result in cardiac death due to a multitude of causes, including arrhythmia, acute heart failure, and myocardial infarction. Recognizing the hemodynamic challenges encountered by LT patients in the perioperative period and how these responses can be exacerbated by underlying cardiac pathology is critical in developing recommendations for the pre-operative risk assessment and management of these patients. The following provides a review of the cardiovascular challenges in LT candidates, as well as evidence-based recommendations for their evaluation and management.

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Section: Pre-operative Cardiovascular Assessment and Managementmentioning

confidence: 48%

Cardiovascular Risk Assessment of the Liver Transplant Candidate

Raval

Harinstein

Skaro

et al. 2011

Journal of the American College of Cardiology

229

174

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“…Other authors [15][16][17] have linked the development of a dynamic outflow tract gradient to negative outcomes. Sharma et al [15] studied 125 renal transplant candidates who underwent DSE and coronary angiography.…”

Section: Discussionmentioning

confidence: 99%

“…Their results demonstrate that DSE-provoked LVOT obstruction is an independent positive predictor of future episodes of chest pain and syncope and/or near syncope. Maraj et al [17] examined 106 consecutive patients who had undergone orthotopic liver transplantation and DSE. They examined outcome differences between two groups: Group I, LVOT gradient >36 mmHg and Group II, LVOT gradient £36 mmHg with respect to intraoperative hypotension, cardiac mortality, length of hospital stay, graft function, and renal function postorthotopic liver transplantation.…”

Section: Discussionmentioning

confidence: 99%

Dynamic left ventricular outflow tract obstruction induced by dobutamine stress echocardiography leading to myocardial ischemia and infarction

Makaryus

Meraj

Rosman

2006

Int J Cardiovasc Imaging

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Left ventricular outflow tract (LVOT) obstruction occurring during dobutamine stress echocardiography (DSE) occurs in approximately 15-20% of patients undergoing DSE. The clinical significance and mechanism of LVOT obstruction has been debated, but is now generally felt to result from the pharmacological effects of dobutamine in increasing inotropy and causing peripheral vasodilation. It must be realized that in rare instances, ischemia may occur and lead to wall motion abnormalities and eventually myocardial infarction. We present the case of a 70-year-old asymptomatic woman who underwent a routine pre-operative cardiac stress evaluation and was found to develop a dynamic outflow tract obstruction leading to myocardial ischemia and infarction.

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“…177 An abnormal noninvasive test or a high pretest probability of CAD (≥2 classical risk factors) is an indication for coronary angiography or cardiac computed tomography angiography. 178 Patients with left ventricular outflow tract obstruction may exhibit a poor tolerance to hemodynamic stress during transplant 179 and careful intraoperative monitoring with trans-esophageal echocardiography is required to avoid tachycardia. Limited use of inotropic agents and transesophageal echocardiography-guided volume administration is advisable to avoid overload of the right ventricle.…”

Section: Cardiovascular Complications In Liver Transplantationmentioning

confidence: 99%