Value of dobutamine stress myocardial contrast perfusion echocardiography in patients with advanced liver disease

Abstract

Although dobutamine stress echocardiography has been used for the preoperative evaluation of patients with advanced liver disease (ALD), no data exist regarding the value of myocardial perfusion imaging (MPI) with real-time myocardial contrast echocardiography (RTMCE) in this patient population. We sought to determine the value of MPI during dobutamine stress RTMCE for predicting prognosis in patients with ALD. We examined both wall motion and MPI in 230 patients with ALD who underwent dobutamine stress RTMCE using intravenous commercially available contrast agents (Optison, GE-Amersham, Princeton, NJ; or Definity, Bristol-Myers Squibb Medical Imaging, North Billerica, MA). The prognostic value of clinical variables, including the Model for End-Stage Liver Disease (MELD) score, and echocardiographic data were examined using a Cox Hazard model. The primary endpoint was mortality of all causes. Among the 85 patients who underwent orthotopic liver transplantation, 4 had abnormal MPI and 81 had normal perfusion. The hospital mortality rate was 50% (2/4) in patients with abnormal MPI and 2% (2/81) in patients with normal MPI (P ϭ 0.01). Among patients with abnormal MPI, 1 died from myocardial infarction in the first postoperative day and the second 1 from hemorrhagic shock. During a median follow-up of 15 months, 53 (23%) patients died. The independent predictors of death were an age of Ն65 yr (RR ϭ 2.2; 95% confidence interval (CI) ϭ 1.1-4.4; P ϭ 0.03), MELD score of Ն25 (RR ϭ 3.2; 95% CI ϭ 1.8-5.5; P Ͻ 0.0001), and abnormal MPI (RR ϭ 2.4; 95% CI ϭ 1.1-5.2; P ϭ 0.02). The 2-yr mortality was 24% for patients with normal MPI and 45% for those with inducible MPI abnormalities (P ϭ 0.003). In conclusion, MPI obtained by RTMCE appears to be a useful tool in predicting mortality in patients with ALD. Further studies are required to verify its independent value.

Diagnostic usefulness of myocardial perfusion imaging in patients reluctant to undergo angiography

“…The 3-year event free survival in patients with normal wall motion and myocardial perfusion was 95% compared to 68% in patients with abnormal wall motion and myocardial perfusion. 51 Similarly, another study of 202 patients with known or suspected CAD who underwent stress echocardiography with MPI showed a hazard ratio of 6.1 for major adverse cardiovascular events in patients with any inducible perfusion defect or wall motion abnormality (a mean follow-up of 32 months). 52 In patients with acute coronary syndrome, MCE has also proven to be a valuable tool.…”

Myocardial Contrast Echocardiography

“…Similar results have been reported in elderly patients 79 as well as in those with diabetes 80,81 and advanced liver disease. 82 As stated earlier, in the current practice of cardiology, some form of stress is required to detect CAD on myocardial perfusion imaging. Unless there is a previous infarction, resting perfusion remains normal despite the presence of up to 85% luminal diameter narrowing of the coronary artery because of autoregulation.…”

II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia

“…Ischemia tests (myocardial scintigraphy and dobutamine echocardiography) have proven to be useful in several studies to assess the candidate for liver transplantation 117,[122][123][124] . When associated with physical exercise protocols, both tests have similar sensitivity and specificity.…”