Preoperative dobutamine stress echocardiographic findings and subsequent short-term adverse cardiac events after orthotopic liver transplantation

Abstract

Cardiovascular (CV) complications are the leading cause of non-graft-related death in orthotopic liver transplant (OLT) patients. Pretransplant cardiac evaluation using dobutamine stress echocardiography (DSE) is commonly utilized for risk stratification of OLT candidates. To determine if clinical and echocardiographic variables identify patients with increased CV risk, we performed a retrospective chart review of all 284 patients that underwent OLT at our institution between June 1999 and August 2005. Of these patients, 157 had a DSE prior to their OLT. Serious adverse CV events occurring during surgery and up to 4 months post-transplantation were defined as cardiac-related death, myocardial infarction (MI), new heart failure, or asystole or unstable ventricular arrhythmia requiring acute treatment. Sixteen of 157 patients (10%) had an adverse CV event with 2 deaths. These included ventricular tachycardia (n ϭ 8), asystole (n ϭ 2), MI (n ϭ 5), and new heart failure (n ϭ 1). Nine of the 16 CV events occurred at the time of surgery (including both deaths), 5 occurred postoperatively, and 3 occurred after hospital discharge. Variables that correlated with increased CV events were inability during DSE to achieve Ͼ82% of the maximum predicted heart rate (22% versus 6%, P ϭ 0.01), a peak rate pressure product during DSE of Ͻ16,333 (17% versus 5%, P ϭ 0.02), and a Model for End-Stage Liver Disease (MELD) score of Ͼ24 at the time of OLT. A multivariate model calculated from the DSE maximum achieved heart rate (MAHR) and MELD score (result ϭ 3.78 ϩ 0.07 MELD Ϫ 0.05 MAHR) identified a 47% risk for a value Ͼ 0 versus a 6% risk for a value Ͻ 0 (P Ͻ 0.001). In conclusion, the maximum heart rate achieved during DSE together with the MELD score may be a predictor of adverse CV events up to 4 months post-OLT. A large prospective study is needed to more decisively support this conclusion.

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

“…In a review of 157 pre-transplant dobutamine stress echocardiographys (DSEs), Umphrey et al [50] found 37% to be inconclusive due to failure to reach 85% of their maximum predicted heart rate.…”

Chronotropic Incompetence on Dobutamine Stress Echocardiography in Candidates for a Liver Transplant

“…[20][21][22] Earlier studies evaluating the DSE as a screening technique for obstructive coronary artery disease in ESLD patients have yielded conflicting results. [7][8][9][10][11] Plotkin and associates concluded that the DSE has sensitivity, specificity, and positive and negative predictive values of 100% 9 ; however, Harinstein and associates reported that the DSE has a poor sensitivity as a screening test for obstructive coronary artery disease in LT candidates and recommend alternate or additional methods for adequate cardiac risk stratification. 2,8 limitations This is a retrospective study based on chart reviews and has a low event rate; therefore, drawing statistical conclusions may be difficult.…”

“…Although various studies have produced conflicting results about the predictive value of DSE in these patients. [7][8][9][10][11] This study sought to determine the prevalence and causes of chronotropic incompetence in patients with ESLD, and to examine the adequacy of our current DSE protocol in predicting cardiac events after an LT.…”

Cardiopulmonary Disease in the Liver Transplant Patient: The Role of Doppler Echocardiography

“…However there has been demonstrated a high negative predictive value of this test. (Umphrey et al 2008). …”