Outcome of liver transplantation for patients with pulmonary hypertension

Abstract

It is generally believed that pulmonary hypertension (PHT) adversely affects outcome after liver transplantation (LT). Most transplant units consider severe PHT to be an absolute contraindication to LT. We examined the outcome of 145 patients who underwent LT between 1997 and 1999. Pulmonary artery pressures (PAPS) had been measured before surgery. Pre-LT workup included electrocardiography and echocardiography for the majority of patients. Also, the liver unit database was screened for patients with known PHT who had undergone LT before 1997. Based on pulmonary floatation catheter measurements made after the induction of anesthesia for LT, PHT was defined as mild or moderate to severe if the mean PAP (MPAP) exceeded 25 and 35 mm Hg, respectively. The incidence of PHT was 26% (38 of 145 patients); 31 of 38 patients had mild PHT. Kaplan-Meier survival analysis did not show a significant survival benefit for patients with normal PAPS compared with patients with PHT (all, mild, moderate to severe). For surviving patients, the duration of ventilation and intensive care unit stay was unaffected by PHT. Four of 5 patients (identified fiom the database 1982 to 1999) with MPAPs greater than 40 mm Hg survived LT by more than 1 year. PHT of this severity was usually associated with specific and suggestive abnormality of the echocardiogram. Mild PHT is common and does not affect patient outcome after LT. Moderate and severe PHT are uncommon. Our analysis suggests that when the cardiac index is preserved, the majority of patients with moderate and severe PHT can survive LT, and they will not die of PHT during long-term follow-up. Echocardiography detects most severe PHT, but not mild and moderate PHT. (Liver TralupZ2002;8:382-388.) A ssessment of cardiovascular and respiratory function are essential elements of the evaluation of the potential liver transplant recipient. Pulmonary vascular disease, particularly pulmonary hypertension (PHT), may cause morbidity and mortality of patients with liver disease before or after liver transplantation (LT). Patients with liver disease and portal hypertension may have many factors that contribute to the development of PHT, including an arterial hyperdynamic circulatory state, increased central venous blood volume, and pulmonary artery vasoconstriction and/or obliteration leading to increased pulmonary vascular resistance. PHT develops in approximately 5% to 10% of patients with portal hypertension.3 PHT may be covert, and recognition requires a high degree of clinical suspicion. Sixty percent of patients with PHT are asymptomatic at the time of diagnosis, and symptoms associated with advanced liver disease and portal hypertension may be indistinguishable from those of PHT of any cause.* A diagnosis of PHT might be suggested by echocardiography, chest radiograph, or electrocardiographic changes.5Treatment options for patients with portal and pulmonary hypertension are few, and the reported mean survival duration after diagnosis is approximately 15 months.6 In an attempt to improve pulmo...

Pulmonary-Hepatic vascular Disorders (PHD)

“…By contrast, there is no increase in mortality if Ppa is f35 mmHg (158,168]. Nonetheless, there are reports of successful OLT and long-term survival in a few patients with a Ppa of w50 mmHg and elevated PVR [265].…”

Successful Liver Transplantation Following Medical Management of Portopulmonary Hypertension: A Single-Center Series

“…Mild disease (PAM <35 mmHg) poses little perioperative risk (5,6), but moderate disease (PAM 35-45 mmHg, pulmonary vascular resistance (PVR) >250 dyn s cm −5 ) has been associated with a perioperative mortality of 50-80% (7,8), and a PAM >50 mmHg is universally fatal (5,7,9). For this reason, liver transplant candidates are routinely screened for POPH, and many centers withhold transplantation if moderate to severe pulmonary hypertension is diagnosed.…”

Treatment with a combination of bosentan and sildenafil allows for successful liver transplantation in a patient with portopulmonary hypertension

“…While the frequency is 3%-6% among patients who are awaiting liver transplantation, it rises to 16% in patients with refractory ascites (3). Annual mortality ranges from 24% to 60% if it is left untreated (3,4). Currently, PPHTN is a rare but serious problem for transplant candidates.…”

“…The operative risk is low in patients with mild PPHTN (PAP<35 mmHg). While mortality due to the transplant surgery itself is 50%-80% in patients with moderate PPHTN (PAP 35-45 mmHg), serious pulmonary hypertension (PAP>50 mmHg) often has a fatal course; thus, the transplant operation is contraindicated (3,4).…”