Dobutamine stress echocardiography for preoperative cardiac risk stratification in patients undergoing orthotopic liver transplantation

Abstract

This study attempts to evaluate the efficacy of dobutamine stress echocardiography for preoperative cardiac risk stratification in patients undergoing orthotopic liver transplantation. Two hundred twenty consecutively submitted patients were evaluated in preparation for orthotopic liver transplantation. Dobutamine stress echocardiography was performed in 80 patients with known or suspected coronary artery disease. Follow-up information was available in 40 patients in the form of cardiac catheterization and/or outcome from liver transplantation to validate the dobutamine stress echo findings. The prevalence of coronary artery disease in this cohort was 5% and was closely associated with the presence of diabetes mellitus. Dobutamine stress echocardiography, when interpreted as abnormal in the presence of wall motion abnormalities only, is associated with a sensitivity, specificity, and positive and negative predictive value of 100%. Dobutamine stress echocardiography is highly efficacious and should be the screening study of choice to detect coronary artery disease in patients undergoing orthotopic liver transplantation. Copyright 1998 by the American Association for the Study of Liver DiseasesO rthotopic liver transplantation (OLT) in patients with coronary artery disease (CAD) is associated with significant morbidity and mortality. 1 Carey et al 2 found that 27% of patients older than 50 years who underwent evaluation for OLT had moderate to severe CAD; the CAD was clinically unsuspected in 13.3% of those with CAD. 3 Furthermore, they identified diabetes mellitus (DM) as an independent risk factor. Despite these data, the ideal preoperative cardiac screening study in patients with end-stage liver disease (ESLD) has yet to be determined. Studies have shown that dobutamine stress echocardiography (DSE) is an accepted technique for the evaluation of CAD in general, 3,4 and more specifically before major vascular surgery 5,6 and kidney transplantation. 7 Donovan et al 8 have shown that the absence of inducible ischemia by DSE confers low risk for myocardial infarction during OLT; however, the inclusion criteria for their study were broad and included many low-risk patients. We therefore sought to evaluate the efficacy of DSE in identifying significant cardiac risk before OLT in the subgroup of patients with a history of and/or significant risk factors for CAD. Materials and MethodsPatient evaluations and decisions regarding cardiac workup were made prospectively; however, the data were analyzed in a retrospective fashion.Two hundred twenty consecutive patients were evaluated for OLT. Careful attention was paid to symptoms of cardiac ischemia and/or risk factors for CAD during the initial evaluation. DSE was performed in 80 patients based on the following criteria: age greater than 50 years but less than 60 with two or more cardiac risk factors (tobacco use, obesity, hypercholesterolemia, hypertension, family history); age greater than than 60 years; presence of active symptoms indicative of CAD; electrocardiographic...

Accuracy of Stress Myocardial Perfusion Imaging to Diagnose Coronary Artery Disease in End Stage Liver Disease Patients

“…Results with dobutamine stress echocardiography have shown poor sensitivity and low negative predictive value, partially because of an inability to reach target heart rate. 2,12,13 Most of these patients are on b blockers to decrease portal hypertension and prevent esophageal bleeding. Ideally, a noninvasive test should be highly sensitive to diagnose CAD in potential transplantation patients, considering the perioperative cardiovascular complication risks involved with the surgery.…”

Detection and treatment of coronary artery disease in liver transplant candidates

“…Morris et al 16 found that 5.6% of 608 patients aged older than 40 years undergoing OLT had documented CAD, although the diagnostic criteria were not explicitly stated. Plotkin et al, 17 using data from both cardiac catheterization and dobutamine stress echocardiogram (DSE), documented significant CAD, defined as 70% or greater stenosis within a major coronary artery, in 2 of 40 patients (5%) who underwent OLT. In another report evaluating the role of DSE in screening patients with cirrhosis for CAD, Donovan et al 18 found that 2.5% of 165 patients had CAD, defined as greater than 50% coronary artery stenosis on cardiac catheterization.…”

“…However, based on data from the 4 studies cited, the prevalence rate ranged from 2.5% to 27% (Table 2). [15][16][17][18] Given a 2.5% prevalence rate of CAD in asymptomatic men in the general population, 19 the former belief that CAD was uncommon in patients with cirrhosis no longer appears to be true. The prevalence rate of CAD in ESLD is at least the same and probably greater than in the general population.…”

“…Plotkin et al 17 performed DSE on 80 patients being evaluated for OLT based on more narrow criteria than those used by Donovan et al 18 All patients with known CAD or diabetes mellitus, patients aged between 50 and 60 years with 2 or more risk factors for CAD, patients older than 60 years of age, and patients with symptoms suggestive of CAD or ECG findings suggestive of ischemia underwent study. Follow-up data with results of cardiac catheterization or clinical outcome of OLT were available in half the patients studied.…”

Stress echocardiography identifies coronary artery disease in liver transplant candidates

“…In this issue of Liver Transplantation and Surgery, Plotkin suggests that I use a diagnostic tool that already has proven efficacy in the general population of patients. 4 In applying this tool, he suggests that I use clinical predictors of CAD that are similar to those suggested by the American College of Cardiology and the American Heart Association. Should we approach the liver transplant candidate in the same fashion as a noncirrhotic patient before some other high risk surgical procedure?…”