Moderate Primary Pulmonary Hypertension in Patients Undergoing Liver Transplantation

Abstract

Primary pulmonary hypertension (PPH) in patients with hepatic cirrhosis is often considered an unacceptable condition for liver transplantation because of increased morbidity and mortality during the procedure. We studied the incidence, characteristics, and final outcome of patients with PPH undergoing liver transplantation in our institution. Among the 226 patients undergoing 257 liver transplantations, eight (3.5%) fulfilled the conditions of PPH and responded to vasodilator therapy. Nitroglycerin 1.5 micrograms/kg produced a decrease in pulmonary vascular resistance index (PVRI) and mean pulmonary arterial pressure (MPAP) of 20% and 15%, respectively. Patients with PPH when compared with a matched group of patients without PPH had markedly increased hemodynamic changes in PVRI (P = 0.004) and MPAP (P = 0.0001) during and after the procedure. All patients with PPH required pulmonary vasodilator therapy after reperfusion of the new liver, while none in the group of patients without PPH required this therapy. Furthermore, after graft reperfusion, patients with PPH in which venovenous bypass was not used (n = 3), had a more compromised right ventricular function with a greater increase of central venous pressure (CVP) (90%) and MPAP (140%) when compared with patients with bypass or preservation of the recipient's vena cava (n = 5) in whom the increase of CVP and MPAP was 50% and 60%, respectively. Moderate PPH without a fixed level of pulmonary hypertension in patients undergoing liver transplantation is not related to an adverse outcome.

The Impact of Treatment of Portopulmonary Hypertension on Survival Following Liver Transplantation

“…Previous studies have shown that patients with mild PPHTN do not have increased mortality or require specific therapy (20–23). In contrast, cirrhotic patients with moderate‐to‐severe pulmonary hypertension have very high mortality (2,6,7,23).…”

Orthotopic liver transplantation in a patient with severe portopulmonary hypertension

“…Our patient demonstrated a significant and persisting decrease in PVR and PAP during an eight‐month period of long‐term epoprostenol therapy. PAP and PVR values in our patient immediately before skin incision were within the range which is well tolerated during OLT if PPH is not treated with epoprostenol (15–17). However, our patient developed perioperative right heart failure, eventually necessitating mechanical circulatory support.…”

“…OLT is well tolerated in patients with only mild or moderate PPH (15–17). Perioperative mortality rates in these patients are comparable to mortality rates in patients without PPH (15–17).…”

“…OLT is well tolerated in patients with only mild or moderate PPH (15–17). Perioperative mortality rates in these patients are comparable to mortality rates in patients without PPH (15–17). Therefore, it has been repeatedly speculated that the marked reduction in PAP observed after epoprostenol therapy in patients with severe PPH may result in a marked decrease in perioperative mortality when undergoing OLT as well (2, 9, 10).…”

“…Therefore, venovenous bypass was not used during the anhepatic phase. The use of venovenous bypass during OLT in all patients with PPH is recommended by Taura and co‐workers (15), as they found a significantly higher cardiac output associated with the use of venovenous bypass in patients with mild or moderate PPH. Use of venovenous bypass or piggy back technique allow more restrictive volume replacement during the anhepatic phase and may therefore offer benefits in patients with PPH.…”