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

Abstract

Portopulmonary hypertension represents a major risk factor for transplantation; therefore, preoperative detection is crucial. The aims of this study were to determine (1) whether Doppler echocardiography performed at evaluation is a reliable tool for detecting portopulmonary hypertension and (2) the incidence of acquired portopulmonary hypertension profile after evaluation. One hundred sixty-five patients had Doppler echocardiography and right heart catheterization at evaluation over a 9-year period. All patients had a prospective follow-up, and the results of catheterization at evaluation were compared with those obtained at the time of transplantation. Seventeen of 165 patients met the criteria for portopulmonary hypertension on Doppler echocardiography. Portopulmonary hypertension was confirmed by catheterization in 10 patients and ruled out in 7. There were no false negatives for echocardiography. Mean pulmonary artery pressure was significantly higher during the initial phase of transplantation than at evaluation (17.8 ؎ 4.3 vs. 20.3 ؎ 5.5 mm Hg, respectively, P < .0001), and there was no significant correlation between values obtained at these 2 time points. Three patients showed to have acquired portopulmonary hypertension profile while waiting for a graft within time intervals ranging from 2.5 to 5 months. In conclusion, Doppler echocardiography is a highly sensitive tool for detecting portopulmonary hypertension. However, because this technique has a poor positive predictive value, right heart catheterization is recommended for confirming portopulmonary hypertension. In addition, the absence of portopulmonary hypertension at evaluation does not exclude the occasional occurrence of acquired portopulmonary hypertension profile after listing. P ulmonary hypertension associated with portal hypertension, the so-called portopulmonary hypertension, is a rare complication of cirrhosis. When severe, this condition is a major risk factor for transplantation because, in most cases, patients are at best partially responsive to medical therapies. 1 If it is impossible to lower mean pulmonary artery pressure below 40 to 50 mm Hg during transplantation procedure, any significant hemodynamic changes, such as those observed at the time of caval clamping and reperfusion of the graft, may result in irreversible cardiac arrest, especially if right ventricular function is impaired. 2 As a consequence, many authors consider that severe portopulmonary hypertension (i.e., mean pulmonary artery pressure [MPAP] above 40 mm Hg) represents a contraindication for liver transplantation because it would carry an unacceptable mortality rate. 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, 4-6 even though this technique ...

Portopulmonary hypertension: Results from a 10-year screening algorithm

“…Despite abnormal echocardiography findings, these patients did not fulfill current diagnostic criteria for POPH. These data are similar to the experience reported by Colle et al, 13 in which 7/17 (41%) patients with abnormal screening echocardiography did not satisfy POPH criteria based on catheter- Abbreviations: MPAP, mean pulmonary artery pressure; CO, cardiac output; PAOP, pulmonary artery occlusion pressure; TPG, transpulmonary pressure gradient; PVR, pulmonary vascular resistance; RVSP, right ventricular systolic pressure; PASP, pulmonary artery systolic pressure; MELD, model for end stage liver disease. ization data.…”

“…The risk in proceeding to liver transplantation in such patients would not appear to be increased from a pulmonary hemodynamic perspective as supported by previous reports. 1,11,13 Catheterization allowed calculation of a transpulmonary gradient (MPAP-PAOP). Importance of the transpulmonary gradient relates to the scenario in which increased pulmonary venous pressure (measured via PAOP) may exist in addition to and further worsen an increased MPAP.…”

“…9 Noninvasive screening for POPH using Doppler echocardiography in liver transplantation candidates has been proposed, [10][11][12] but reports of echocardiography-right heart catheterization relationships are few with limited interpretation of right heart catheterization results. 1,10,11,13,14 We report the results of our prospective screening echocardiography-right heart catheterization algorithm conducted in consecutive liver transplantation candidates at the Mayo Clinic from 1996 to 2005. We categorized pulmonary hemodynamic results based on PVR, the key concept that characterizes obstruction to pulmonary arterial flow.…”

Chronic pulmonary arterial hypertension in children

“…(10) Other conditions which also exhibit features of pulmonary arterial hypertension are portopulmonary hypertension, (11) where it has major implications for survival (50% to 72% over 2 years), (12) exposure to certain toxic agents such as appetite suppressants derived from amphetamine, (13) and of signifi cance in Southern Africa, human immunodefi ciency virus (HIV) infection. (14) Pulmonary arterial hypertension and left heart disease…”

Portopulmonary hypertension: Diagnostic advances and caveats

“…5 Those patients went on to RHC, and 10 of 17 satisfied the generally accepted criteria for POPH (mean pulmonary artery pressure (MPAP) Ͼ25 mm Hg; pulmonary vascular resistance (PVR) Ͼ 120 dynes ⅐ s ⅐ cm Ϫ5 ; and normal pulmonary capillary wedge pressure Ͻ 15 mm Hg). There were no false negatives.…”