201
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Rapid normalization of portopulmonary hypertension after living donor liver transplantation. Transplant Proc 2009; 41:1976-8. [PMID: 19545772 DOI: 10.1016/j.transproceed.2009.02.095] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 01/10/2009] [Accepted: 02/17/2009] [Indexed: 11/21/2022]
Abstract
Portopulmonary hypertension (PPHTN) is a relatively rare complication of end-stage liver disease, and a serious problem in the context of liver transplantation. Herein we have reported a case of decompensated liver cirrhosis with PPHTN, which rapidly resolved after adult-to-adult living donor liver transplantation (LDLT). A 54-year-old man was referred to our hospital with end-stage liver cirrhosis owing to chronic hepatitis C. Preoperative mean pulmonary artery pressure (mPAP), as assessed by right heart catheterization, was 38 mm Hg. Continuous infusion of epoprostenol decreased the mPAP to 24 mm Hg over 44 days. He underwent LDLT using a right hepatic lobe graft donated by his son. The postoperative course was uneventful, epoprostenol was weaned by postoperative day (POD) 21, and the mPAP normalized to 21 mm Hg on POD 28. The patient was discharged on POD 31 without any vasodilators. Our case revealed that liver transplantation can rapidly resolve PPTHN.
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202
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, Beghetti M, Corris P, Gaine S, Gibbs JS, Gomez-Sanchez MA, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30:2493-537. [PMID: 19713419 DOI: 10.1093/eurheartj/ehp297] [Citation(s) in RCA: 2217] [Impact Index Per Article: 147.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nazzareno Galiè
- Institute of Cardiology, Bologna University Hospital, Via Massarenti, 9, 40138 Bologna, Italy.
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203
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Abstract
Advanced liver disease and portal hypertension produce various intrathoracic complications that involve the pleural space, the lung parenchyma, and the pulmonary circulation. Dyspnea and arterial hypoxemia are the most common symptoms and signs in patients with such complications. This article focuses on the diagnosis and management of hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. All are pulmonary processes associated with end-stage liver disease that lead to significant morbidity and affect the quality of life of patients who are suffering from liver cirrhosis.
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Affiliation(s)
- C Singh
- Santa Barbara Cottage Hospital, 675 Central Avenue, Apartment 5, Buellton, CA 93427, USA
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204
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Shen M, Zhang F, Zhang X. Pulmonary hypertension in primary biliary cirrhosis: a prospective study in 178 patients. Scand J Gastroenterol 2009; 44:219-23. [PMID: 18821172 DOI: 10.1080/00365520802400883] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED OBJECTIVE. To analyze the incidence, clinical features, and prognosis of patients with primary biliary cirrhosis (PBC) complicated by pulmonary hypertension (PH). MATERIAL AND METHODS A total of 178 consecutive PBC patients, who were admitted to Peking Union Medical College Hospital from January 2001 to March 2007, were included in this prospective study. A structured interview, systemic rheumatological examination, laboratory tests (including autoantibodies), and Doppler echocardiography were conducted for each patient and compared between patients with and without PH. RESULTS Twenty-one PBC patients (11.8%) had PH. Among them, four patients (19.0%) had moderate to severe PH, and one patient died of right heart failure instead of liver failure. The incidences of Raynaud's phenomenon, interstitial lung disease, Sjögren's syndrome, and portal hypertension, the proportion of patients with a positive anti-SSA, the level of serum IgA, as well as the Mayo risk score in the PH-PBC patients were significantly higher than in the non-PH-PBC group (p = 0.02, 0.001, 0.02, 0.03, 0.006, 0.04 and 0.02, respectively). CONCLUSIONS PH, including moderate to severe PH, is not a rare complication of PBC. This complication is closely associated with portal hypertension and immunological dysregulation and indicates a poor prognosis.
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Affiliation(s)
- Min Shen
- Department of Rheumatology and Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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205
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Abstract
After around 64,000 transplantations in Europe since 1988 liver transplantation has emerged as a standard treatment option for otherwise incurable chronic liver diseases. Cirrhosis of different etiologies represents the most frequent transplant indication. Overall survival in this group amounts to 72% after 5 years, and 62% after 10 years. In Germany, the main indications include alcoholic liver cirrhosis, tumors with increasing numbers in recent years, as well as viral diseases leading to cirrhosis. Since December 2006 the priority for liver transplantation is determined by the model for end stage liver disease (MELD) and not by the length of waiting time. MELD is a statistical model based on serum creatinine, serum bilirubin and coagulation, which describes the probability of 3-month mortality of a potential transplant candidate. Not all liver diseases are adequately represented by MELD necessitating the additional use of a defined number of standard exceptions that have been last updated in 2008. As a consequence of these developments indications, selection of recipients and the management of the waiting list have seen profound change.
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206
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Kim YK, Kim Y, Shim SS. Thoracic Complications of Liver Cirrhosis: Radiologic Findings. Radiographics 2009; 29:825-37. [DOI: 10.1148/rg.293085093] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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207
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Suga K, Kawakami Y, Iwanaga H, Tokuda O, Matsunaga N. Findings of hepatopulmonary syndrome on breath-hold perfusion SPECT-CT fusion images. Ann Nucl Med 2009; 23:413-9. [PMID: 19396512 DOI: 10.1007/s12149-009-0250-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 01/27/2009] [Indexed: 01/29/2023]
Abstract
Pulmonary perfusion SPECT-CT fusion images were used to characterize CT manifestations of intrapulmonary arteriovenous communications (AVC) causing right-to-left shunt and hepatopulmonary syndrome (HPS). After scanning the whole body and obtaining multiple view images of the lung, deep-inspiratory breath-hold (DIBrH) SPECT was obtained in 2 patients with HPS, which was automatically and three-dimensionally co-registered with DIBrH CT. In both patients, the whole body scan depicted systemic organs and confirmed the existence of right-to-left shunt. DIBrH SPECT-CT fusion images showed that perfusion defects were predominantly located at subpleural reticulo-nodular opacities and/or dilated vessels in the lung base. Subpleural reticulo-nodular opacities and/or dilated vessels in the lung base appear to be characteristic CT manifestation of intrapulmonary AVC in HPS.
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Affiliation(s)
- Kazuyoshi Suga
- Department of Radiology, St. Hill Hospital, 1462-3 Nishikiwa, Ube, Yamaguchi, 755-0151, Japan.
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208
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Kim JS, Kim C, Kim GS, Lim DS, Hwang HK, Ro YM. A Case of Hepatopulmonary Syndrome in a Patient with Child-Pugh Class A Liver Cirrhosis. Tuberc Respir Dis (Seoul) 2009. [DOI: 10.4046/trd.2009.66.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jung Sun Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Changhwan Kim
- Department of Internal Medicine and Sejong Medical Research Institute, Sejong General Hospital, Bucheon, Korea
| | - Gye Su Kim
- Department of Internal Medicine and Sejong Medical Research Institute, Sejong General Hospital, Bucheon, Korea
| | - Dal Soo Lim
- Department of Internal Medicine and Sejong Medical Research Institute, Sejong General Hospital, Bucheon, Korea
| | - Hweung Kon Hwang
- Department of Internal Medicine and Sejong Medical Research Institute, Sejong General Hospital, Bucheon, Korea
| | - Young Moo Ro
- Department of Internal Medicine and Sejong Medical Research Institute, Sejong General Hospital, Bucheon, Korea
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209
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Hino T, Hayashida A, Okahashi N, Wada N, Watanabe N, Obase K, Neishi Y, Kawamoto T, Okura H, Yoshida K. Portopulmonary hypertension associated with congenital absence of the portal vein treated with bosentan. Intern Med 2009; 48:597-600. [PMID: 19367055 DOI: 10.2169/internalmedicine.48.1715] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Portopulmonary hypertension (PPHTN) is pulmonary arterial hypertension (PAH) associated with portal hypertension. It is a common condition among liver transplantation candidates; however, its association with congenital absence of the portal vein (CAPV) has not yet been established. CAPV is a very rare developmental anomaly, which is usually accompanied by abnormal mesenteric drainage that bypasses the liver. Here, we report a rare case of severe PPHTN secondary to CAPV.
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Affiliation(s)
- Tomoko Hino
- Postgraduate Clinical Training Center, Kawasaki Medical School Hospital Kurashaki, Japan.
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210
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Mauritz GJ, Marcus JT, Boonstra A, Postmus PE, Westerhof N, Vonk-Noordegraaf A. Non-invasive stroke volume assessment in patients with pulmonary arterial hypertension: left-sided data mandatory. J Cardiovasc Magn Reson 2008; 10:51. [PMID: 18986524 PMCID: PMC2584621 DOI: 10.1186/1532-429x-10-51] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 11/05/2008] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) is an emerging modality in the diagnosis and follow-up of patients with pulmonary arterial hypertension (PAH). Derivation of stroke volume (SV) from the pulmonary flow curves is considered as a standard in this respect. Our aim was to investigate the accuracy of pulmonary artery (PA) flow for measuring SV. METHODS Thirty-four PAH patients underwent both CMR and right-sided heart catheterisation. CMR-derived SV was measured by PA flow, left (LV) and right ventricular (RV) volumes, and, in a subset of nine patients also by aortic flow. These SV values were compared to the SV obtained by invasive Fick method. RESULTS For SV by PA flow versus Fick, r = 0.71, mean difference was -4.2 ml with limits of agreement 26.8 and -18.3 ml. For SV by LV volumes versus Fick, r = 0.95, mean difference was -0.8 ml with limits of agreement of 8.7 and -10.4 ml. For SV by RV volumes versus Fick, r = 0.73, mean difference -0.75 ml with limits of agreement 21.8 and -23.3 ml. In the subset of nine patients, SV by aorta flow versus Fick yielded r = 0.95, while in this subset SV by pulmonary flow versus Fick yielded r = 0.76. For all regression analyses, p < 0.0001. CONCLUSION In conclusion, SV from PA flow has limited accuracy in PAH patients. LV volumes and aorta flow are to be preferred for the measurement of SV.
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Affiliation(s)
- Gert-Jan Mauritz
- Department of Pulmonary Diseases, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - J Tim Marcus
- Department of Physics and Medical Technology, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Anco Boonstra
- Department of Pulmonary Diseases, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Pieter E Postmus
- Department of Pulmonary Diseases, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Diseases, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
- Department of Physiology, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Diseases, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
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211
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Gonzalez LF, Leal D, Vidal CA, Zuluaga D, Ariza F, Giraldo C. Síndrome hepatopulmonar y trasplante hepático. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2008. [DOI: 10.1016/s0120-3347(08)64009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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212
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Alveolar Exhaled Nitric Oxide is Elevated in Hereditary Hemorrhagic Telangiectasia. Lung 2008; 187:43-9. [DOI: 10.1007/s00408-008-9125-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 10/01/2008] [Indexed: 01/26/2023]
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213
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214
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Dickel T, Turnbull A, Pye M. Fatal acute cor pulmonale due to portopulmonary hypertension in a noncirrhotic patient. Int J Clin Pract 2008; 62:1453-4. [PMID: 18793380 DOI: 10.1111/j.1742-1241.2005.00792.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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215
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Witters P, Maleux G, George C, Delcroix M, Hoffman I, Gewillig M, Verslype C, Monbaliu D, Aerts R, Pirenne J, Van Steenbergen W, Nevens F, Fevery J, Cassiman D. Congenital veno-venous malformations of the liver: widely variable clinical presentations. J Gastroenterol Hepatol 2008; 23:e390-4. [PMID: 17868331 DOI: 10.1111/j.1440-1746.2007.05156.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIM Congenital portosystemic veno-venous malformations are rare abnomalities that often remain undiagnosed. Typically they are classified by their anatomical characteristics according to Morgan (extrahepatic, Abernethy malformations type Ia,b and II) and Park (intrahepatic, types 1-4). However, their clinical presentation is less dependent on the anatomical type. METHOD We reviewed the clinical characteristics of six cases drawn from our files (from 1970 to 2006). RESULTS One patient, a 25-year-old male, had extrahepatic shunting whereby the liver receives only arterial blood because the portal vein (PV) connects with the inferior caval vein (ICV) (Abernethy Ib); he presented with episodes of jaundice and pruritus. Three patients had extrahepatic shunting with patent intrahepatic portal veins, but with shunting of splenomesenterial blood towards the ICV (Abernethy II); these included a 66-year-old male with hepatic encephalopathy, a 17-year-old female with (porto?-)pulmonary hypertension without portal hypertension, and a 33-year-old female with epidsodes of acute pain secondary to spontaneous bleeding within a primary liver tumor. Two patients had intrahepatic shunting; these included an 8-year-old boy who was diagnosed incidentally during work-up for abnormal liver enzymes with a communication between right PV and ICV (Park type 1), and a 59-year-old male with multiple PV-ICV-shunts in several liver segments (Park, type 4) who presented with hepatic encephalopathy. CONCLUSION Patients often present with signs of hepatic shunting (encephalopathy, pulmonary hypertension, hepatopulmonary syndrome, and/or hypoglycemia) with relative sparing of the synthetic liver function in the absence of portal hypertension. Some shunts present with space-occupying lesions (focal nodular hyperplasia, hepatocellular carcinoma, nodular regenerative hyperplasia, etc.) or biliary atresia. Finally, some cases are detected incidentally.
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Affiliation(s)
- Peter Witters
- Laboratory of Hepatology, Catholic University of Leuven, Leuven, Belgium.
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216
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Praus A, Eicken A, Balling G, Schreiber C, Hess J. Progressive intrapulmonary shunting in a child after bidirectional Glenn operation only resolved after total cavopulmonary completion. Int J Cardiol 2008; 128:e12-5. [PMID: 17706305 DOI: 10.1016/j.ijcard.2007.04.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 04/25/2007] [Indexed: 11/28/2022]
Abstract
We report on a girl with progressive intrapulmonary shunting after bidirectional Glenn (BDG) operation and resolution of these microscopic fistulas after completion to total cavopulmonary connection (TCPC).
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217
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Indications for and outcomes after combined lung and liver transplantation: a single-center experience on 13 consecutive cases. Transplantation 2008; 85:524-31. [PMID: 18347530 DOI: 10.1097/tp.0b013e3181636f3f] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Combined lung and liver transplantation (Lu-LTx) is a therapeutic option for selected patients with coexisting lung and liver disease. For several reasons, Lu-LTx is performed in few centers and information about the technical issues, posttransplant management and long-term outcomes associated with this procedure is limited. METHODS We analyzed data from 13 consecutive patients who underwent combined Lu-LTx at Hannover Medical School (Hannover, Germany) between April 1999 and December 2003. The main indications were cystic fibrosis, alpha1-proteinase inhibitor deficiency and portopulmonary hypertension. All patients had advanced cirrhosis and severe pulmonary disease manifestation. RESULTS Ten patients received a sequential double Lu-LTx, one patient received a single Lu-LTx, one received a double lung and split liver transplantation, and one received an en-bloc heart-lung and liver transplantation. Immunosuppression was based on cyclosporine in a triple/quadruple regimen. Postoperative surgical complications occurred in eight patients. There were two perioperative deaths; two patients died during the first year on day 67 and 354, respectively, and one patient died at month 53. The overall patient survival rates at 1, 3, and 5 years were 69%, 62%, and 49%, respectively. CONCLUSION Combined Lu-LTx is a therapeutic option for highly selected patients with end-stage lung and liver disease with acceptable long-term outcome.
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218
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Márquez Martín E, Jara Palomares L, Ortega Ruiz F, Grilo Bensusán I, López-Campos JL, Cejudo Ramos P, Pascasio JM, Rodríguez Becerra E. [Hepatopulmonary syndrome in patients with advanced hepatic disease: study of a series of 24 cases]. Med Clin (Barc) 2008; 130:98-102. [PMID: 18261381 DOI: 10.1157/13115351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVE To describe the characteristics observed in patients diagnosed of hepatopulmonary syndrome (HPS) waiting for orthotopic liver transplantation and those who underwent liver trasplantation. PATIENTS AND METHOD An observational prospective descriptive study was carried out of patients waiting for liver transplantation in whom data of liver illness and lung function tests were analyzed. RESULTS 107 patients of 53.69 years average age were studied (7.7 standard deviation). 24 of them (22.4%) had criteria of HPS. Ortodeoxia was present in the 34% of cases. The lung function tests were normal. In the comparative study between patients with HPS and no HPS, differences in diffusion were found (7.1 vs. 8.6 mmol/min/kPa; p = 0.04), as well as in the shunt (8% vs. 5.3%; p = 0.05) and the forced expiratory volume in one second (2,390 vs. 2,743 ml; p = 0.03). Seven patients were transplanted with correction of oxygenation and vascular dilatations in all of them. CONCLUSIONS HPS is a frequent illness in patients waiting for orthotopic liver transplantation. The main alteration in the blood oxygenation seems owe to shunt, and the diffusion tests is the analysis that could best differentiate patients with HPS. Orthotopic liver transplantation corrects the syndrome in all cases.
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Affiliation(s)
- Eduardo Márquez Martín
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospitales Universitarios Virgen del Rocío, Sevilla, España.
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219
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Cool CD, Deutsch G. Pulmonary arterial hypertension from a pediatric perspective. Pediatr Dev Pathol 2008; 11:169-77. [PMID: 18275254 DOI: 10.2350/07-12-0398.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Accepted: 02/02/2008] [Indexed: 11/20/2022]
Abstract
This review of pediatric pulmonary arterial hypertension provides a framework within which to view pulmonary hypertension in children. Classification schemes, including the latest recommendations from the World Health Organization, are discussed, and the histopathology of severe pulmonary hypertension is reviewed. New information is provided regarding idiopathic and familial forms of the disease. Specific childhood etiologies, including persistent pulmonary hypertension of the newborn and congenital heart disease, are reviewed. Additionally, we examine the role of collagen vascular diseases, portal hypertension, and viruses in the pathogenesis of severe pulmonary arterial hypertension.
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Affiliation(s)
- Carlyne D Cool
- University of Colorado Health Sciences Center, Department of Pathology, Denver, CO, USA.
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220
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Steinbis S. Portopulmonary Hypertension and Liver Transplantation: What Does it Mean for Your Patient? J Nurse Pract 2008. [DOI: 10.1016/j.nurpra.2007.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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221
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Austin MJ, McDougall NI, Wendon JA, Sizer E, Knisely AS, Rela M, Wilson C, Callender ME, O'Grady JG, Heneghan MA. Safety and efficacy of combined use of sildenafil, bosentan, and iloprost before and after liver transplantation in severe portopulmonary hypertension. Liver Transpl 2008; 14:287-91. [PMID: 18306330 DOI: 10.1002/lt.21310] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Portopulmonary hypertension (PPHTN) represents a constrictive pulmonary vasculopathy in patients with portal hypertension. Liver transplantation (LT) may be curative and is usually restricted to patients with mild-to-moderate disease severity characterized by a mean pulmonary artery pressure (mPAP < 35 mm Hg). Patients with severe disease (mPAP > 50 mm Hg) are usually excluded from transplantation. We describe a patient with severe PPHTN, initiated on sequential and ultimately combination therapy of prostacyclin, sildenafil, and bosentan (PSB) pretransplantation and continued for 2 years posttransplantation. Peak mPAP on PSB therapy was dramatically reduced from 70 mm Hg to 32 mm Hg pretransplantation, and continued therapy facilitated a further fall in mPAP to 28 mm Hg posttransplantation. The pulmonary vascular resistance index fell from 604 to 291 dyne second(-1) cm(-5). The perioperative mPAP rose to 100 mm Hg following an episode of sepsis and fell with optimization of PSB therapy. In conclusion, this is the first reported patient with severe PPHTN using this combination of vasodilator therapy as a bridge to LT and then as maintenance in the posttransplantation phase. This regimen may enable LT in similar patients in the future, without long-term consequences.
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Affiliation(s)
- Mark J Austin
- Institute of Liver Studies, King's College Hospital, London, England
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222
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Ferreira PP, Camara EJN, Paula RLPD, Zollinger CC, Cavalcanti AR, Bittencourt PL. Prevalence of hepatopulmonary syndrome in patients with decompensated chronic liver disease and its impact on short-term survival. ARQUIVOS DE GASTROENTEROLOGIA 2008; 45:34-7. [DOI: 10.1590/s0004-28032008000100007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 08/15/2007] [Indexed: 01/28/2023]
Abstract
BACKGROUND: Hepatopulmonary syndrome is reported to occur in 4% to 32% of the patients with chronic liver disease and is associated with poor liver function and shortened patient survival before and after liver transplantation. AIMS: To assess the frequency of hepatopulmonary syndrome in Brazilian patients with decompensated chronic liver disease and to investigate its impact on patient survival. METHODS: One hundred and thirty patients (101 males, mean age 61 ± 12 years) with decompensated chronic liver disease were evaluated for the presence of hepatopulmonary syndrome. The diagnosis of hepatopulmonary syndrome was considered in the presence of alveolar arterial oxygen gradient of more than 15 mm Hg and of pulmonary vascular dilatation assessed by contrast enhanced echocardiography. RESULTS: Hepatopulmonary syndrome was observed in 21 (16%) patients. The presence of hepatopulmonary syndrome was significantly associated with severity of liver disease assessed by the MELD (Model for End-Stage Liver Disease) score, but not with in hospital mortality after admission due to decompensated chronic liver disease. CONCLUSIONS: Hepatopulmonary syndrome occurs in 16% of patients with chronic liver disease and is associated with disease severity according to the MELD score. Short term mortality following decompensation of chronic liver disease was not associated with hepatopulmonary syndrome.
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224
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Saad NE, Lee DE, Waldman DL, Saad WE. Pulmonary Arterial Coil Embolization for the Management of Persistent Type I Hepatopulmonary Syndrome after Liver Transplantation. J Vasc Interv Radiol 2007; 18:1576-80. [DOI: 10.1016/j.jvir.2007.08.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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225
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Abstract
Hepatopulmonary syndrome is characterized by advanced liver disease, hypoxemia, and intrapulmonary shunting. The only reported curative option is orthotopic liver transplantation. We describe here a beneficial effect of inhaled prostacyclin including a decrease in respiratory symptoms and improved oxygenation in this clinical situation, with no approved pharmacological long-term therapy. The prostanoid iloprost, approved for pulmonary and portopulmonary hypertension, caused an increase in oxygenation, relief of dyspnea, and increased exercise tolerance in a patient suffering from liver-cirrhosis-associated hepatopulmonary syndrome. After liver transplantation, restitution of hepatopulmonary syndrome did not occur immediately. Inhaling iloprost resulted in improved physical condition and better clinical rehabilitation potential until hypoxemia finally resolved 3 months after transplantation. Therefore, iloprost could improve quality of life in patients with hepatopulmonary syndrome waiting for liver transplantation and post surgery until the resolution of the hypoxemia.
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226
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Frossard JL, Schiffer E, Cikirikcioglu B, Bourquin J, Morel DR, Pastor CM. Opposite regulation of endothelial NO synthase by HSP90 and caveolin in liver and lungs of rats with hepatopulmonary syndrome. Am J Physiol Gastrointest Liver Physiol 2007; 293:G864-70. [PMID: 17921448 DOI: 10.1152/ajpgi.00136.2007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The hepatopulmonary syndrome is a complication of cirrhosis that associates an overproduction of nitric oxide (NO) in lungs and a NO defect in the liver. Because endothelial NO synthase (eNOS) is regulated by caveolin that decreases and heat shock protein 90 (HSP90) that increases NO production, we hypothesized that an opposite regulation of eNOS by caveolin and HSP90 might explain the opposite NO production in both organs. Cirrhosis was induced by a chronic bile duct ligation (CBDL) performed 15, 30, and 60 days before sample collection and pharmacological tests. eNOS, caveolin, and HSP90 expression were measured in hepatic and lung tissues. Pharmacological tests to assess NO released by shear stress and by acetylcholine were performed in livers (n = 28) and lungs (n = 28) isolated from normal and CBDL rats. In lungs from CBDL rats, indirect evidence of high NO production induced by shear stress was associated with a high binding of HSP90 and a low binding of caveolin to eNOS. Opposite results were observed in livers from CBDL rats. Our study shows an opposite posttranslational regulation of eNOS by HSP90 and caveolin in lungs and liver from rats with CBDL. Such opposite posttranslational regulation of eNOS by regulatory proteins may explain in part the pulmonary overproduction of NO and the hepatic NO defect in rats with hepatopulmonary syndrome.
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Affiliation(s)
- Jean-Louis Frossard
- Laboratoire de Physiopathologie Hépatique et Imagerie Moléculaire, Hôpitaux Universitaires de Genève, Rue Micheli-du-Crest, 24, 1205 Geneva, Switzerland
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227
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Busani S, Rinaldi L, Barbieri E, Drago A, Barbieri A, Girardis M. Peri-operative respiratory failure in a cirrhotic patient: a misleading diagnosis. Anaesthesia 2007; 62:963-5. [PMID: 17697229 DOI: 10.1111/j.1365-2044.2007.05175.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with chronic liver disease may present with different degrees of respiratory dysfunction whose differential diagnosis is important before elective surgery. We report the case of a misleading diagnosis of peri-operative respiratory failure in a cirrhotic patient who underwent mastectomy. Intra-operative respiratory failure was ascribed by the anaesthetic team to pulmonary embolism and after the operation this diagnosis was still suspected. Despite postoperative heparin treatment, pulmonary gas exchange remained severely impaired. On the hypothesis of a right to left shunt, we performed transoesophageal echocardiography with a bubble test and confirmed hepatopulmonary syndrome. We administered anticoagulant therapy to the patient following surgery, increasing the risk of haemorrhage. We also continued orotracheal intubation and mechanical ventilation longer than was needed. Respiratory symptoms in a patient with liver disease should not be underestimated and up to 20% of these patients may have hepatopulmonary syndrome.
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Affiliation(s)
- S Busani
- Cattedra e Divisione di Anestesiologia e Rianimazione, Università di Modena e Reggio Emilia, Policlinico di Modena, Largo del Pozzo, 71. 41100 Modena, Italy.
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228
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Liver transplantation and pulmonary hypertension: pathophysiology and management strategies. Curr Opin Organ Transplant 2007; 12:274-280. [DOI: 10.1097/mot.0b013e32814a599c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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229
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Fix OK, Bass NM, De Marco T, Merriman RB. Long-term follow-up of portopulmonary hypertension: effect of treatment with epoprostenol. Liver Transpl 2007; 13:875-85. [PMID: 17539008 DOI: 10.1002/lt.21174] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Moderate to severe portopulmonary hypertension (PPHTN) increases the risks of orthotopic liver transplantation (OLT). Epoprostenol is an effective treatment of PPHTN, but long-term effects on pulmonary hemodynamics or liver function in PPHTN are poorly defined. We sought to describe the long-term effects of treatment with or without epoprostenol on pulmonary hemodynamics, liver biochemistries, and survival in patients with moderate to severe PPHTN at a single center. A large retrospective cohort was identified with moderate to severe PPHTN diagnosed before OLT. Baseline and follow-up pulmonary hemodynamics and liver biochemistries were compared and outcomes assessed. Nineteen patients were treated with epoprostenol and 17 were not treated with epoprostenol. There were significant improvements in mean pulmonary artery pressure (MPAP, 48.4-36.1 mm Hg; P < 0.0001), pulmonary vascular resistance (PVR, 632-282 dynes . s . cm(-5); P < 0.0001), and cardiac output (5.7 to 7.7 L/min; P = 0.0009) with epoprostenol after a median of 15.4 months. Liver biochemistries did not change significantly, and survival did not seem to differ between the 2 groups (hazard ratio, 0.85; P = 0.77). In the epoprostenol group, patients who survived had greater absolute changes in MPAP, transpulmonary gradient, and PVR than those who died. Two patients in the epoprostenol group successfully underwent OLT. Long-term epoprostenol therapy greatly improves pulmonary hemodynamics in patients with PPHTN. Liver biochemistries are not greatly changed. Survival seemed not to differ between treatment groups. A minority of patients treated with epoprostenol will improve sufficiently to undergo OLT.
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Affiliation(s)
- Oren K Fix
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
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230
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Abstract
As a result of the success of orthotopic liver transplantation, there has been increasing interest in the diagnosis and therapeutic options for the pulmonary vascular complications of hepatic disease. These pulmonary vascular complications range from the hepatopulmonary syndrome, which is characterized by intrapulmonary vascular dilatations, to portopulmonary hypertension (POPH), which is characterized by an elevated pulmonary vascular resistance as a consequence of obstruction to pulmonary arterial blood flow. This review concentrates on POPH.
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Affiliation(s)
- Jason M Golbin
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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231
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Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. ACTA ACUST UNITED AC 2007; 4:266-76. [PMID: 17476209 DOI: 10.1038/ncpgasthep0794] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 03/13/2007] [Indexed: 12/13/2022]
Abstract
Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.
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Affiliation(s)
- A James Hanje
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH 43210, USA
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232
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Hendrickse A, Azam F, Mandell MS. Hepatopulmonary syndrome and portopulmonary hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:127-36. [PMID: 17484815 DOI: 10.1007/s11936-007-0006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The incidence of pulmonary vascular disorders is significantly increased in patients with liver disease. Intrapulmonary shunting with hypoxemia in patients with liver disease is diagnosed as hepatopulmonary syndrome (HPS), whereas precapillary pulmonary vessel obliteration is identified as portopulmonary hypertension (PPHTN). Because the symptoms of liver disease can mimic those of pulmonary vascular disease, all patients with hepatic failure should be screened for these two diseases. Pulse oximetry effectively screens for hypoxemia associated with HPS, whereas an elevated right ventricular systolic pressure estimated by echocardiography identifies patients at risk of having PPHTN. Liver transplantation is the only effective medical therapy for HPS. However, those who have a resting arterial oxygenation less than 50 mm Hg or a shunt measured by scintigraphic perfusion greater than 20% have an unacceptably high mortality rate following surgery. Compared with HPS, there are more therapeutic options that can bridge patients with PPHTN to transplantation. Drugs used to manage idiopathic pulmonary hypertension have shown promise in the treatment of PPHTN. Prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors have improved transplant survival. Despite treatment, however, perioperative mortality for patients with PPHTN remains high. Even with successful transplantation, HPS and PPHTN can persist or develop de novo. Long-term follow-up and surveillance of liver transplant recipients is thus indicated to identify HPS and PPHTN following surgery.
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Affiliation(s)
- Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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233
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Ashfaq M, Chinnakotla S, Rogers L, Ausloos K, Saadeh S, Klintmalm GB, Ramsay M, Davis GL. The impact of treatment of portopulmonary hypertension on survival following liver transplantation. Am J Transplant 2007; 7:1258-64. [PMID: 17286619 DOI: 10.1111/j.1600-6143.2006.01701.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pulmonary hypertension in the setting of cirrhosis and portal hypertension is known as portopulmonary hypertension (PPHTN). Moderate or severe PPHTN is uncommon, but has a poor prognosis and is considered to be a contraindication to liver transplantation. We assessed the impact of vasodilation therapy on pulmonary hemodynamics and outcome after liver transplant in these patients. Eighty-six patients evaluated for liver transplant between 1997 and 2005 had an estimated right ventricular systolic pressure >40 mm Hg or a clinical suspicion of PPHTN. Right heart catheterization confirmed PPHTN in 30 patients (ten mild, eight moderate, and 12 severe). Sixteen of the 20 with moderate-to-severe pulmonary hypertension (mPAP >or= 35) were otherwise considered suitable liver transplant candidates and were treated with vasodilation therapy. mPAP fell to less than 35 mm Hg in 12 patients (75%) and 11 of them then underwent orthotopic liver transplantation. One- and five-year survivals in the transplanted patients were 91% and 67%, respectively. Nine of 11 were off vasodilator therapy after a median of 9.2 months following transplantation. None of the patients who failed vasodilator therapy survived (median survival, 8 months). Effective pharmacologic control of PPHTN before liver transplant is associated with excellent posttransplant survival that is similar to patients transplanted for other indications.
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Affiliation(s)
- M Ashfaq
- Department of Medicine, Baylor Regional Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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234
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Sanz J, Kuschnir P, Rius T, Salguero R, Sulica R, Einstein AJ, Dellegrottaglie S, Fuster V, Rajagopalan S, Poon M. Pulmonary Arterial Hypertension: Noninvasive Detection with Phase-Contrast MR Imaging. Radiology 2007; 243:70-9. [PMID: 17329691 DOI: 10.1148/radiol.2431060477] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively identify pulmonary arterial (PA) flow parameters measured with phase-contrast magnetic resonance (MR) imaging that allow noninvasive diagnosis of chronic PA hypertension (PAH). MATERIALS AND METHODS The study was HIPAA compliant and was approved by the institutional review board; a waiver of informed consent was obtained. Fifty-nine patients (49 female patients; mean age, 46 years; range, 16-85 years) known to have or suspected of having PAH underwent breath-hold phase-contrast MR imaging and right-sided heart catheterization (RHC). The presence of PAH (mean pulmonary artery pressure [mPAP], >25 mm Hg) was confirmed in 42 patients. Parameters, including PA areas, PA strain, average velocity, peak velocity, acceleration time, and ejection time, were measured in each patient by investigators blinded to RHC results. These measurements were correlated with mPAP, systolic pulmonary artery pressure (sPAP), and pulmonary vascular resistance index (PVRI). The diagnostic ability of phase-contrast MR imaging to depict PAH was quantified. Statistical tests included Spearman rho coefficients, receiver operating characteristic curve analysis, and Bland-Altman plots. RESULTS Results showed average velocity to have the best correlation with mPAP, sPAP, and PVRI (r = -0.73, -0.76, and -0.86, respectively; P < .001). Average velocity (cutoff value = 11.7 cm/sec) revealed PAH with a sensitivity of 92.9% (39 of 42) and a specificity of 82.4% (14 of 17). Sensitivity and specificity for the minimum PA area (cutoff value = 6.6 cm(2)) were 92.9% (39 of 42) and 88.2% (15 of 17), respectively. CONCLUSION The average blood velocity throughout the cardiac cycle is strongly correlated with pulmonary pressures and resistance.
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Affiliation(s)
- Javier Sanz
- Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY 10029, USA.
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235
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Tieppo J, Vercelino R, Dias AS, Silva Vaz MF, Silveira TR, Marroni CA, Marroni NP, Henriques JAP, Picada JN. Evaluation of the protective effects of quercetin in the hepatopulmonary syndrome. Food Chem Toxicol 2007; 45:1140-6. [PMID: 17306429 DOI: 10.1016/j.fct.2006.12.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Revised: 12/18/2006] [Accepted: 12/25/2006] [Indexed: 11/21/2022]
Abstract
The hepatopulmonary syndrome (HPS) occurs when intrapulmonary dilatation causes hypoxemia in cirrhosis. The free radicals may play a significant contributory role in the progression of HPS, and flavonoid agents could protect against deleterious effects of free radicals. The flavonoid quercetin was evaluated in an experimental model of biliary cirrhosis induced by bile duct ligation (BDL) in rats. Quercetin was administered at 50mg/kg for 14 days to cirrhotic and non-cirrhotic rats. Bone marrow was extracted from animals to analyze micronuclei. Lung, liver and blood were extracted to detect DNA damage using the comet assay. The results showed that the micronuclei and DNA damages to lung and liver were increased in BDL rats. Quercetin caused no damage to the DNA while decreasing the occurrence of micronucleated cells in bone marrow as well as DNA damage to lung and liver in cirrhotic rats. Quercetin showed antimutagenic activity against hydroperoxides as evaluated by the oxidative stress sensitive bacterial strains TA102 Salmonella typhimurium and IC203 Escherichia coli, suggesting protection by free radical scavenging. In Saccharomyces cerevisie yeast strains lacking mitochondrial or cytosolic superoxide dismutase, these results indicate that quercetin protects cells by induction of antioxidant enzymes. The present study is the first report of genotoxic/antigenotoxic effects of quercetin in a model of animal cirrhosis. In this model, quercetin was not able to induce genotoxicity and, conversely, it increased the genomic stability in the cirrhotic rats, suggesting beneficial effects, probably by its antioxidant properties.
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Affiliation(s)
- J Tieppo
- Hospital de Clínicas de Porto Alegre, HCPA/Universidade Federal do Rio Grande do Sul, UFRGS, 90035-903, Laboratório de Hepatologia Experimental, Fisiologia, Ramiro Barcelos, 2350 Porto Alegre, RS, Brazil
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236
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Kim SJ, Lee EJ, Jung KH, Kang EH, Lee SY, Lim HE, Yim HJ, Lee SY, Kim JH, Shin C, Shim JJ, In KH, Kang KH, Yoo SH. A Case of Portopulmonary Hypertension Associated with Primary Biliary Cirrhosis. Tuberc Respir Dis (Seoul) 2007. [DOI: 10.4046/trd.2007.62.5.421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Se Joong Kim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Eun Ju Lee
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Ki Hwan Jung
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Eun Hae Kang
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Sung Yong Lee
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hong Euy Lim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Sang Yeub Lee
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Je Hyeong Kim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Chol Shin
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Jae Jeong Shim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Kwang Ho In
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Kyung Ho Kang
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Se Hwa Yoo
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
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237
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Affiliation(s)
- Mark T Keegan
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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238
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McElhinney DB, Kreutzer J, Lang P, Mayer JE, del Nido PJ, Lock JE. Incorporation of the hepatic veins into the cavopulmonary circulation in patients with heterotaxy and pulmonary arteriovenous malformations after a Kawashima procedure. Ann Thorac Surg 2006; 80:1597-603. [PMID: 16242423 DOI: 10.1016/j.athoracsur.2005.05.101] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2005] [Revised: 05/04/2005] [Accepted: 05/09/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND In patients with polysplenia syndrome and azygous continuation of an interrupted inferior vena cava (IVC), pulmonary arteriovenous malformations (PAVMs) are relatively common after bidirectional cavopulmonary anastomosis (BCPA, Kawashima procedure). Resolution of PAVMs after hepatic vein (HV) inclusion into the cavopulmonary circulation has been reported, but there has been no systematic investigation of the effects of this therapy in a population of more than 3 patients. METHODS We studied 16 patients with heterotaxy, univentricular congenital heart disease, and azygous continuation of the IVC who underwent incorporation of the HV into the cavopulmonary circuit for treatment of significant PAVMs after a Kawashima procedure. RESULTS The median preoperative systemic arterial oxygen saturation (SsaO2) was 76% (65%-85%), compared with 89% (85% to 92%) early after BCPA. Among 15 early survivors, the median early postoperative SsaO2 was 76% (56%-85%). In 11 of the 15 survivors, SsaO2 rose to 90% or greater within a year and remained at 93% or greater at follow-up of 2.8 to 10 years. Four patients had persistent hypoxemia and residual PAVMs at follow-up catheterization 1.5 to 8 years postoperatively; these patients had the most severe hypoxemia prior to HV inclusion, and in 2 the residual PAVMs were unilateral, with HV flow streaming to the contralateral lung, in which PAVMs had resolved. CONCLUSIONS Hypoxemia resolved after cavopulmonary incorporation of the HV in the majority of our patients with PAVMs after the Kawashima operation, presumably due to a combination of PAVM resolution and elimination of hepatic venoatrial right-to-left shunting. These findings support the theory that development of PAVMs is facilitated by exclusion of HV effluent from the pulmonary circulation.
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Affiliation(s)
- Doff B McElhinney
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
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239
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Gohh RY, Warren G. The Preoperative Evaluation of the Transplanted Patient for Nontransplant Surgery. Surg Clin North Am 2006; 86:1147-66, vi. [PMID: 16962406 DOI: 10.1016/j.suc.2006.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
With the improved success of solid-organ transplantation, there has been an increased willingness to transplant individuals previously felt to be unsuitable for such procedures. Factors such as age and various medical comorbidities are no longer considered contraindications to transplantation, and hence, an increasing number of recipients may require medical care not specifically related to the transplant. After transplantation, many of these patients may require elective or emergent surgery, making it important for all surgeons to be familiar with the factors that may influence surgical outcomes in this population, asa well asa factors that affect postoperative care. Most transplant centres use a team approach to manage these complex patients, relying on medical professionals experienced in their care and management. Close interaction with the transplant team is likely the single most important step in preparing the transplanted patient for surgery and managing their postoperative care.
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Affiliation(s)
- Reginald Y Gohh
- Division of Renal Diseases, Rhode Island Hospital, Brown University School of Medicine, 593 Eddy Street, APC-921, Providence, Rhode Island 02903, USA.
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240
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Barth F, Gerber PJ, Reichen J, Dufour JF, Nicod LP. Efficiency and safety of bosentan in child C cirrhosis with portopulmonary hypertension and renal insufficiency. Eur J Gastroenterol Hepatol 2006; 18:1117-9. [PMID: 16957519 DOI: 10.1097/01.meg.0000231749.60889.f7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bosentan has lately been described as a successful therapeutic agent for portopulmonary hypertension consecutive to child A cirrhosis. This is the first report of the effect of this substance with advanced liver cirrhosis (child C) and renal insufficiency. Low doses of bosentan (initially twice 31.25 mg/day and then 62.5 mg/day) increased cardiac output and allowed correction of renal insufficiency; it allowed one to stop the requirement of oxygen and not only improved the 6-min walking test by more than 400 m, but also decreased the severity of the liver cirrhosis to child B stadium. This suggests that patients, who would be excluded from a liver transplantation program because of their portopulmonary hypertension, could profit from a careful therapy with bosentan.
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Affiliation(s)
- Florian Barth
- Clinic and Policlinic of Pneumology, Inselspital, Switzerland
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241
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Halank M, Ewert R, Seyfarth HJ, Hoeffken G. Portopulmonary hypertension. J Gastroenterol 2006; 41:837-47. [PMID: 17048047 DOI: 10.1007/s00535-006-1879-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 07/25/2006] [Indexed: 02/04/2023]
Abstract
Portopulmonary hypertension (PPHT) is defined as precapillary pulmonary hypertension accompanied by hepatic disease or portal hypertension. Pulmonary hypertension results from excessive pulmonary vascular remodeling and vasoconstriction. These histological alterations have been indistinguishable from those of other forms of pulmonary arterial hypertension. Factors involved in the pathogenesis of PPHT include volume overload, hyperdynamic circulation, and circulating vasoactive mediators. The disorder has a substantial impact on survival and requires focused treatment. Liver transplantation in patients with moderate to severe PPHT is associated with a significantly reduced survival rate. The best medical treatment for patients with PPHT is controversial; most authors currently regard continuous intravenous application of prostacyclin as the treatment of choice for patients with severe PPHT. There is only very limited reported experience with inhaled prostacyclin or its analog, iloprost. Increasing evidence of the efficacy of the endothelin-receptor antagonist bosentan and of the phosphodiesterase-5 inhibitor sildenafil is emerging in highly selected patients with PPHT. In the future, a combination therapy of the above-mentioned agents might become a therapeutic option. Other agents such as beta-blockers seem to be harmful to patients with moderate to severe portopulmonary hypertension. Up-to-date, randomized, double-blind, controlled clinical trials are lacking and are needed urgently.
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Affiliation(s)
- Michael Halank
- Carl Gustav Carus University Dresden, Internal Medicine I, Fetscherstr. 74, 01307 Dresden, Germany
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242
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Tumgor G, Ozkan T, Ulger Z, Kilic M, Aydogdu S. Liver transplantation of a child with child a cirrhosis and severe hepatopulmonary syndrome. Transplant Proc 2006; 38:1432-4. [PMID: 16797324 DOI: 10.1016/j.transproceed.2006.02.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2005] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a clinical state defined by a chronic hepatic disorder, intrapulmonary vascular dilatation, and altered gas exchange resulting in hypoxemia. Cirrhosis of the liver is the most common condition associated with HPS. A 3-year-old boy who presented with end-stage liver disease and severe hepatopulmonary syndrome underwent orthotopic liver transplantation (OLT). The findings of HPS resolved immediately after OLT. His status is within normal limits at 6 months after liver transplantation.
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Affiliation(s)
- G Tumgor
- Department of Pediatric Gastroenterology/Hepatology/Nutrition and Organ Transplantation and Research Center, Ege University School of Medicine, Izmir, Turkey.
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243
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Rapp C, Defuentes G, Imbert P, Debord T. Hepatopulmonary syndrome: an emerging complication in HIV-hepatitis C virus co-infected patients. AIDS 2006; 20:1679-80. [PMID: 16868454 DOI: 10.1097/01.aids.0000238419.51560.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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244
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Schiffer E, Majno P, Mentha G, Giostra E, Burri H, Klopfenstein CE, Beaussier M, Morel P, Hadengue A, Pastor CM. Hepatopulmonary syndrome increases the postoperative mortality rate following liver transplantation: a prospective study in 90 patients. Am J Transplant 2006; 6:1430-7. [PMID: 16686767 DOI: 10.1111/j.1600-6143.2006.01334.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a frequent pulmonary complication of patients with end-stage liver diseases. HPS is diagnosed by hypoxemia and pulmonary vascular dilatation and is an independent risk factor of mortality. Orthotopic liver transplantation (OLT) is the only factor that modifies the natural course of HPS. Once patients with HPS have been transplanted, their long-term survival rate is similar to transplanted patients without HPS. Consequently, HPS is an indication of OLT whatever the severity of hypoxemia. However, besides the favorable long-term survival of HPS patients with OLT, a high postoperative mortality (mostly within 6 months) has been suggested. The aim of our study was to analyze the incidence of HPS and postoperative outcome after OLT in 90 consecutive patients. All patients were prospectively included and had blood gas analysis to detect HPS. Patients with hypoxemia had contrast echocardiography to confirm HPS. Nine patients had HPS with a 50 </= PaO(2)</= 70 mmHg. Among them 3 (33%) died while the mortality rate was 9.2% in the group without HPS (7 over 76 patients). In the HPS patients who survived, the syndrome completely recovered within 6 months. In conclusion, our study shows a high postoperative mortality rate following OLT even though the preoperative PaO(2) was >50 mmHg in all HPS patients transplanted.
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Affiliation(s)
- E Schiffer
- Service d'Anesthésiologie, Département APSI, Hopitaux Universitaires de Geneve, 1205 Geneva, Switzerland.
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245
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Ramsay MA. Portopulmonary Hypertension and Hepatopulmonary Syndrome, and Liver Transplantation. Int Anesthesiol Clin 2006; 44:69-82. [PMID: 16832207 DOI: 10.1097/01.aia.0000210800.60630.ac] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Michael A Ramsay
- Department of Anesthesiology, Baylor University Medical Center, Dallas, TX 75246, USA
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246
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Wang YW, Lin HC, Yang YY, Hou MC, Lee SD. Sildenafil decreased pulmonary arterial pressure but may have exacerbated portal hypertension in a patient with cirrhosis and portopulmonary hypertension. J Gastroenterol 2006; 41:593-7. [PMID: 16868809 DOI: 10.1007/s00535-006-1809-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2006] [Accepted: 03/01/2006] [Indexed: 02/04/2023]
Abstract
Portopulmonary hypertension is a recognized but uncommon complication of cirrhosis. Liver transplantation may be contraindicated in patients with severe portopulmonary hypertension. In order to decrease the pulmonary arterial pressure, intravenous administration of epoprostenol has been shown to provide substantial beneficial results in these patients. Additionally, a recent case report demonstrated that long-term oral administration of sildenafil decreased pulmonary arterial pressure, but its effects on splanchnic hemodynamics were not measured. We report on a patient with cirrhosis and portopulmonary hypertension and the changes in the hemodynamic status after an oral administration of sildenafil. This case report clearly delineates that sildenafil decreases pulmonary arterial pressure but may exacerbate portal hypertension and hyperdynamic circulation in patients with cirrhosis and portopulmonary hypertension.
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Affiliation(s)
- Ying-Wen Wang
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, 201, Section 2, Shih-Pai Road, Taipei, 11217, Taiwan
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247
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Shirouzu Y, Kasahara M, Takada Y, Taira K, Sakamoto S, Uryuhara K, Ogawa K, Doi H, Egawa H, Tanaka K. Development of pulmonary hypertension in 5 patients after pediatric living-donor liver transplantation: de novo or secondary? Liver Transpl 2006; 12:870-5. [PMID: 16628693 DOI: 10.1002/lt.20758] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The development of portopulmonary hypertension (PH) in a patient with end-stage liver disease is related to high cardiac output and hyperdynamic circulation. However, PH following liver transplantation is not fully understood. Of 617 pediatric patients receiving transplants between June 1990 and March 2004, 5 (median age 12 yr, median weight 24.5 kg) were revealed to have portopulmonary hypertension (PH) after living-donor liver transplantation (LDLT), as confirmed by echocardiography and/or right heart catheterization. All children underwent LDLT for post-Kasai biliary atresia. In 2 patients with refractory biliary complications, PH developed following portal thrombosis; 2 with stable graft function, who had had intrapulmonary shunting (IPS) before LDLT, were found to have PH in spite of overcoming liver dysfunction due to hepatitis. PH developed shortly after distal splenorenal shunting in 1 patient, who suffered liver cirrhosis due to an intractable outflow blockage. The onset of PH ranged from 2.8 to 11 yr after LDLT, and mean pulmonary artery pressure (mPAP) estimated by echocardiography at the time of presentation ranged from 43 to 120 mmHg. Three of the 5 patients are alive under prostaglandin I2 (PGI2) treatment. Of these, 1 is prepared for retransplantation for an intractable complications of liver allograft, while the other 2 with satisfactory grafts are being considered for lung transplantation. Even after LDLT, PH can develop with portal hypertension. Periodic echocardiography is essential for early detection and treatment of PH especially in the recipients with portal hypertension not only preoperatively but also postoperatively.
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Affiliation(s)
- Yasumasa Shirouzu
- Department of Transplant Surgery, Kyoto University Hospital, Kyoto, Japan.
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248
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Sakuma M, Souma S, Kitamukai O, Demachi J, Takahashi T, Suzuki J, Nawata J, Sugimura K, Oikawa M, Saji K, Tada T, Fukui S, Kagaya Y, Watanabe J, Shirato K. Portopulmonary hypertension: hemodynamics, pulmonary angiography, and configuration of the heart. Circ J 2006; 69:1386-93. [PMID: 16247216 DOI: 10.1253/circj.69.1386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The goal of the present study was to examine the cardiac configuration and pulmonary vascular changes in patients with portopulmonary hypertension (PPHTN) and compare them with those of idiopathic pulmonary arterial hypertension (IPAH). METHODS AND RESULTS The subjects were 10 patients with PPHTN and 18 with IPAH. In PPHTN, the increases in the right ventricular end-diastolic volume index (89+/-19 vs 128+/-50 ml/m2; p=0.04), right end-systolic volume index (50+/-19 vs 95+/-47 ml/m 2; p=0.02) and right ventricular mass index (47+/-18 g/m2 vs 79+/-31; p=0.04) were low compared with IPAH. The decrease in the right ventricular ejection fraction was also low in PPHTN (45+/-10 vs 28+/-13%; p=0.01). The degree of sparse arborization and abrupt narrowing on wedged pulmonary angiography was moderate in PPHTN compared with IPAH. In PPHTN, the proximal pulmonary arteries were dilated near the segmental arteries, which were narrow in IPAH. CONCLUSION Changes in the configuration of the heart were moderate in PPHTN compared with those in IPAH. The degree of sparse arborization and abrupt narrowing were also moderate in PPHTN.
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Affiliation(s)
- Masahito Sakuma
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine,Sendai, Japan.
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249
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Ratti L, Pozzi M. The pulmonary involvement in portal hypertension: portopulmonary hypertension and hepatopulmonary syndrome. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:40-50. [PMID: 16393630 DOI: 10.1016/s0210-5705(06)71595-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary abnormalities are common in patients with advanced chronic liver disease. Two distinct syndromes strictly related to the presence of portal hypertension, but clearly different from a pathophysiologic point of view, have been identified. Portopulmonary hypertension, characterized by an increased pulmonary arterial pressure, is due to a progressive arteriolar vasoconstriction induced by excess local production of vasoconstrictor substances. Hepatopulmonary syndrome results from intrapulmonary microvascular dilation caused by an inadequate synthesis or metabolism of putative pulmonary vasoactive substances leading to a functional vasodilation of the pulmonary vasculature, ultimately leading to hypoxemia. Controversies on pathogenesis imply different tentative therapeutic approaches for the medical management of these conditions. The development of portopulmonary hypertension or the hepatopulmonary syndrome has important clinical and prognostic implications facing the impact of new therapeutic strategies for the management of the main complications of advanced liver diseases on cardiopulmonary function.
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Affiliation(s)
- L Ratti
- Clínica Medica, Università Milano-Bicocca, Azienda Ospedaliera San Gerardo, Monza, Italy
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250
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Uchiyama H, Soejima Y, Taketomi A, Yoshizumi T, Harada N, Ijichi H, Yonemura Y, Maehara Y. Successful adult-to-adult living donor liver transplantation in a patient with moderate to severe portopulmonary hypertension. Liver Transpl 2006; 12:481-4. [PMID: 16498645 DOI: 10.1002/lt.20691] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portopulmonary hypertension (PPHTN) is one of the most devastating consequences of end-stage liver cirrhosis. When a patient has moderate to severe PPHTN, his or her candidature for liver transplantation is denied. Here we report a successful adult-to-adult living donor liver transplantation (LDLT) in a patient with moderate to severe PPHTN. The patient was a 58-yr-old female who was diagnosed with end-stage liver cirrhosis due to chronic hepatitis C. Preoperative evaluation revealed that the patient had moderate to severe PPHTN. Her mean pulmonary artery pressure (mPAP) was 35-47 mmHg without treatment. Continuous epoprostenol therapy was introduced to lower the mPAP. She underwent LDLT using an extended right hepatic lobe graft which was donated by her daughter. Prolonged artificial ventilation was necessary until postoperative day (POD) 25, after which her general condition gradually improved. By POD 72, she was in good condition and was allowed to leave the hospital. Currently, 1 yr after the operation, she visits the outpatient clinic regularly and enjoys a normal life. It should be noted, however, that the PPHTN markedly improved but did not completely resolve, as assessed by right heart catheterization 1 yr after successful LDLT.
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Affiliation(s)
- Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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