In the setting of moderate to severe pulmonary artery hypertension, orthotopic liver transplantation (OLT) may be complicated by pulmonary hemodynamic instability and cardiopulmonary mortality. We retrospectively studied the relationship between cardiopulmonary-related mortality and initial (untreated) pre-OLT pulmonary hemodynamics in 43 patients with portopulmonary hypertension who underwent attempted OLT. Thirty-six patients were reported in 18 peer-reviewed studies, and 7 patients underwent OLT at our institution since 1996. Transplantation procedure outcome, mean pulmonary artery pressure (MPAP), pulmonary vascular resistance (PVR), cardiac output, pulmonary capillary wedge pressure, and transpulmonary gradient (TPG) are summarized. Overall mortality was reported in 15 of 43 patients (35%). Fourteen of the 15 deaths (93%) were primarily related to cardiopulmonary dysfunction. Two deaths were intraoperative, 8 deaths occurred during the transplantation hospitalization, and 4 patients died of cardiopulmonary deterioration posthospitalization. In 4 patients, the transplantation procedure could not be successfully completed. Cardiopulmonary mortality was associated with greater pre-OLT MPAP (49 ؎ 14 v 36 ؎ 7 mm Hg; P F .005), PVR (441 ؎ 173 v 261 ؎ 156 dynes·s·cm Ϫ5 ; P F .005), and TPG (37 ؎ 13 v 22 ؎ 10 mm Hg; P F .005). MPAP of 50 mm Hg or greater was associated with 100% cardiopulmonary mortality. In patients with an MPAP of 35 to less than 50 mm Hg and PVR of 250 dynes·s·cm Ϫ5 or greater, the mortality rate was 50%. No mortality was reported in patients with a pre-OLT MPAP less than 35 mm Hg or TPG less than 15 mm Hg. Cardiopulmonaryrelated mortality in OLT patients with portopulmonary hypertension was frequent and associated with significantly increased pre-OLT MPAP, PVR, and TPG compared with survivors. Treated or untreated, we recommend intraoperative cancellation or advise against proceeding to OLT for an MPAP of 50 mm Hg or greater. Patients with an MPAP of 35 to less than 50 mm Hg and PVR of 250 dynes·s·cm Ϫ5 or greater appear to be at high risk for cardiopulmonary-related mortality after OLT. A prospective study is needed to define optimal pretransplantation treatments and pulmonary hemodynamic criteria that minimize OLT mortality associated with portopulmonary hypertension. (Liver Transpl 2000;6:443-450.) P ortopulmonary hypertension is defined as pulmonary artery hypertension (mean pulmonary artery pressure [MPAP], Ͼ25 mm Hg and pulmonary capillary wedge pressure [PCWP] less than 15 mm Hg) in association with portal hypertension. 1-3 Several investigators adhere to the additional criteria of increased pulmonary vascular resistance ([PVR] Ͼ120 dynes·s·cm Ϫ5 ). [4][5][6] A unifying hypothesis explaining the cause of this liver-lung relationship has yet to be proven. 2 Patients with portopulmonary hypertension have a high mortality rate. Within 15 months from the time pulmonary hypertension was diagnosed, death was reported in 38% (10 of 26 patients) to 41% (32 of 78 patients) of the patients describ...

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Surveys suggest that most patients have a spiritual life and regard their spiritual health and physical health as equally important. Furthermore, people may have greater spiritual needs during illness. We reviewed published studies, meta-analyses, systematic reviews, and subject reviews that examined the association between religious involvement and spirituality and physical health, mental health, health-related quality of life, and other health outcomes. We also reviewed articles that provided suggestions on how clinicians might assess and support the spiritual needs of patients. Most studies have shown that religious involvement and spirituality are associated with better health outcomes, including greater longevity, coping skills, and health-related quality of life (even during terminal illness) and less anxiety, depression, and suicide. Several stud

Combination of an obstructive sleep apnea screening tool preoperatively (SACS) and recurrent PACU respiratory events was associated with a higher oxygen desaturation index and postoperative respiratory complications. A two-phase process to identify patients at higher risk for perioperative respiratory desaturations and complications may be useful to stratify and manage surgical patients postoperatively.

Pulmonary hypertension associated with increased pulmonary vascular resistance (PVR) and occurring in the setting of portal hypertension is referred to as ''portopulmonary hypertension.'' Intravenous epoprostenol (prostacyclin) is a potent pulmonary and systemic vasodilator with antithrombotic properties. It can decrease PVR and pulmonary artery pressure in patients with primary (idiopathic) pulmonary hypertension. Using right-heart catheterization, we evaluated the acute pulmonary hemodynamic effects of intravenous epoprostenol in patients with moderate to severe pulmonary hypertension (mean pulmonary artery pressure [MPAP] H35 mm Hg) associated with clinical manifestations of portal hypertension. Effects of long-term infusion of epoprostenol were also evaluated. We studied 15 consecutive patients with portopulmonary hypertension; 14 underwent acute administration of epoprostenol, and no significant side effects were noted. Ten patients received continuous epoprostenol (range, 8 days-30 months). Acute changes in PVR (؊34% ؎ 18%), MPAP (؊16% ؎ 10%), and cardiac output (CO) (؉21 ؎ 18%), were statistically significant (P F .01). Long-term use of epoprostenol further lowered PVR (؊47% ؎ 12% from baseline and ؊31% ؎ 22% from the acute change; P F .05) in the 6 patients restudied by right-heart catheterization. Death occurred in 6 of 10 (60%) of those receiving long-term epoprostenol. In moderate to severe portopulmonary hypertension, intravenous epoprostenol resulted in a significant improvement (both acute and long-term) in PVR, MPAP, and CO. Potential adverse effects on portal hypertension and implications for orthotopic liver transplantation (OLT), however, require further study. (HEPATOLOGY 1999;30:641-648.)Pulmonary hypertension is defined as a mean pulmonary artery pressure (MPAP) Ͼ 25 mm Hg at rest determined by right-heart catheterization. 1 Patients with portal hypertension have multiple factors that contribute to the development of pulmonary arterial or venous hypertension. Such factors include an arterial hyperdynamic circulatory state (increased cardiac output [CO]), increased central venous volume (associated with an elevated pulmonary capillary wedge pressure [PCWP]) and pulmonary artery vasoconstriction/ obliteration (increased pulmonary vascular resistance with a normal PCWP). [2][3][4] In the setting of portal hypertension, the development of a vasoconstrictive/obliterative process affecting the pulmonary arterial bed causing increased pulmonary vascular resistance (PVR) has been described as ''portopulmonary hypertension. '' 4,5 Histopathology of the pulmonary arterial lesions associated with portal hypertension is indistinguishable from that seen in primary pulmonary hypertension.

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Pulmonary hypertension has been associated with poor outcome after liver transplantation. We assessed the diagnostic accuracy of Doppler echocardiography in detecting significant pulmonary hypertension. Seventyfour potential liver transplant candidates underwent Doppler echocardiography in which the systolic right ventricular pressure (RVsys) was used to estimate the systolic pulmonary artery pressure (PAsys). Group 1 included 39 consecutive patients with RVsys H50 mm Hg who underwent elective right heart catheterization. Group 2 consisted of 35 patients with RVsys F50 mm Hg in whom pulmonary artery pressures were measured at the beginning of the transplantation procedure. The accuracy of the estimates by Doppler echocardiography was assessed against measurements made by direct catheterization. Patients in groups 1 and 2 were comparable in their demographic and liver disease characteristics. There was a strong correlation between RVsys by Doppler echocardiography and PAsys by right heart catheterization (r ‫؍‬ .78, P F .01). Of the 39 patients in group 1, 29 (72%) had at least moderate pulmonary hypertension (mean pulmonary artery pressure [MPAP] H35 mm Hg), including 12 (30%) with severe pulmonary hypertension (MPAP H50 mm Hg). Only 1 of the group 2 patients had MPAP H35 mm Hg. Thus, in the diagnosis of moderate to severe pulmonary hypertension, the sensitivity of echocardiography was 97% and specificity was 77%. Doppler echocardiography is an accurate screening test to detect moderate to severe pulmonary hypertension. We advise that liver transplant candidates with RVsys H50 mm Hg undergo right heart catheterization to fully characterize pulmonary hemodynamics. (Liver Transpl 2000;6:453-458.) P ulmonary hypertension is not uncommonly encountered in patients with advanced liver disease. Portopulmonary hypertension (PPH) is the most significant type of pulmonary hypertension, and it may be seen in up to 9% of patients with advanced liver disease. 1,2 PPH is defined hemodynamically by increased mean pulmonary artery pressure (MPAP Ͼ25 mm Hg) and normal volume status or pulmonary capillary wedge pressure (PCWP Ͻ15 mm Hg) in patients with chronic liver disease and portal hypertension. 3 An additional criterion of increased pulmonary vascular resistance (PVR Ͼ120 dyne · s · cm Ϫ5 ) is favored by some investigators. 4 This latter condition further emphasizes the pulmonary arterial pressureflow relationship.The exact pathophysiologic mechanism causing pulmonary arterial hypertension in these patients remains to be elucidated. 5 It is believed that pulmonary vasoconstriction and the high flow state associated with hepatic dysfunction plays an important part early in the pathogenesis. 1 Autopsy studies have shown vascular medial hypertrophy, intimal fibrosis, and plexogenic arteriopathy with or without thrombotic change in varying degrees. 6 The hemodynamic correlates and reversibility of these lesions are poorly understood.In the context of orthotopic liver transplantation (OLT), PPH has been associated with poor outco...

Risk factors have been identified for patients with cirrhosis who undergo anesthesia and surgery.