1
|
McGinn R, McCluskey SA, Sayed BA, Goto T, Chan CT, Murphy P. Intraoperative hemodialysis with supra- and infradiaphragmatic catheters for liver transplantation. Can J Anaesth 2024; 71:1165-1171. [PMID: 38877135 DOI: 10.1007/s12630-024-02777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024] Open
Abstract
PURPOSE The benefits of intraoperative dialysis during orthotopic liver transplantation remain controversial. In patients with anuric renal failure and portopulmonary hypertension, maintaining venous return during caval clamping and unclamping along with minimizing fluid overload is critical to avoiding right ventricular strain and failure. CLINICAL FEATURES We present the case of a 54-yr-old female who underwent orthotopic liver transplantation for alcohol-related liver disease with acute decompensation including severe hepatorenal syndrome (anuric requiring dialysis), probable hepatopulmonary syndrome, moderate pulmonary hypertension (right ventricular systolic pressure, 44 mm Hg), hepatic encephalopathy (grade 2), and esophageal varices. Prior to incision, pulmonary arterial pressures were 48/28 (mean, 35) mm Hg with a central venous pressure of 30 mm Hg, cardiac output of 7.4 L·min-1, and pulmonary vascular resistance of 98 dynes·sec·cm-5. In the context of right ventricular strain and volume overload observed on transthoracic echocardiography, we inserted an additional dialysis catheter into the right femoral vein. We initiated dialysis using the two catheters as a circuit (femoral line to the dialysis machine; blood was reinjected via the subclavian line) acting as a limited venovenous bypass, allowing right ventricular offloading and hemodialysis throughout the case. We removed 4.5 L via hemodialysis during the surgery, while avoiding acidosis, hyperkalemia, and sodium shifts. The patient tolerated reperfusion adequately despite pre-existing right ventricular dilation and dysfunction. CONCLUSION We report on the use two hemodialysis catheters in a patient undergoing orthotopic liver transplantation as a circuit for simultaneous anuric hepatorenal syndrome and moderate pulmonary hypertension with right ventricular dilation and dysfunction. We believe this technique was instrumental in the patient's successful transplant.
Collapse
Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Blayne A Sayed
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Toru Goto
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Patricia Murphy
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth St, 3EN-464, Toronto, ON, M5G 2C4, Canada.
| |
Collapse
|
2
|
Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Portopulmonary hypertension: peculiarities of diagnosis and treatment. EMERGENCY MEDICINE 2024; 20:146-158. [DOI: 10.22141/2224-0586.20.3.2024.1686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portopulmonary hypertension is defined as the development of pulmonary hypertension secondary to portal one. Its exact prevalence is difficult to determine due to the lack of routine screening in patients with portal hypertension. Hemodynamic changes associated with portal hypertension, including the hyperdynamic state, portosystemic shunts, and splanchnic vasodilation, cause significant disturbances in the pulmonary vasculature and play a key role in the pathogenesis of the disease. Without treatment, portopulmonary hypertension leads to progressive right ventricular failure with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and candidates for liver transplant, right heart catheterization remains the gold standard for disease diagnosis. Treatment of patients with portopulmonary hypertension is aimed at improving cardiac function, reducing pulmonary vascular resistance, and optimizing functional capacity. Pulmonary hypertension-specific therapy, which includes prostacyclin and its receptor agonists, endothelin receptor antagonists, phosphodiesterase inhibitors, and guanylate cyclase stimulators, plays a key role in the treatment of patients with portopulmonary hypertension. Small uncontrolled and recent single randomized controlled trials have reported promising results of vasodilator therapy in terms of clinical and hemodynamic improvement in patients, allowing certain patients to undergo liver transplantation. This review discusses the epidemiology, approach to diagnosis and treatment of patients with portopulmonary hypertension. We used MEDLINE database on the PubMed platform and the Cochrane library to search for literature sources using the keywords: portopulmonary hypertension, portal hypertension, pulmonary hypertension, liver cirrhosis, pulmonary complications.
Collapse
|
3
|
Tamura Y, Tamura Y, Taniguchi Y, Atsukawa M. Current clinical understanding and effectiveness of portopulmonary hypertension treatment. Front Med (Lausanne) 2023; 10:1142836. [PMID: 37081835 PMCID: PMC10110923 DOI: 10.3389/fmed.2023.1142836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/28/2023] [Indexed: 04/07/2023] Open
Abstract
Portopulmonary hypertension (PoPH) is a rare subtype of Group 1 pulmonary arterial hypertension (PAH) with a poor prognosis. According to the most up-to-date definition, PoPH is characterized by a mean pulmonary arterial pressure (PAP) of >20 mmHg at rest, a pulmonary artery wedge pressure of ≤15 mmHg, and a pulmonary vascular resistance (PVR) of >2 Wood units with portal hypertension. Like PAH, PoPH is underpinned by an imbalance in vasoactive substances. Therefore, current guidelines recommend PAH-specific therapies for PoPH treatment; however, descriptions of the actual treatment approaches are inconsistent. Given the small patient population, PoPH is often studied in combination with idiopathic PAH; however, recent evidence suggests important differences between PoPH and idiopathic PAH in terms of hemodynamic parameters, treatment approaches, survival, socioeconomic status, and healthcare utilization. Therefore, large, multi-center registry studies are needed to examine PoPH in isolation while obtaining statistically meaningful results. PoPH has conventionally been excluded from clinical drug trials because of concerns over hepatotoxicity. Nevertheless, newer-generation endothelin receptor antagonists have shown great promise in the treatment of PoPH, reducing PVR, PAP, and World Health Organization functional class without causing hepatotoxicity. The role of liver transplantation as a treatment option for PoPH has also been controversial; however, recent evidence shows that this procedure may be beneficial in this patient population. In the future, given the shortage of liver donors, predictors of a favorable response to liver transplantation should be determined to select the most eligible patients. Collectively, advances in these three areas could help to standardize PoPH treatment in the clinic.
Collapse
Affiliation(s)
- Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Japan
- *Correspondence: Yuichi Tamura,
| | - Yudai Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
4
|
The correlation in echocardiogram to right heart catheterization in identifying pulmonary hypertension as a barrier to liver transplantation. Am J Med Sci 2023; 365:496-501. [PMID: 36933862 DOI: 10.1016/j.amjms.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/31/2022] [Accepted: 03/09/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) and portopulmonary hypertension (POPH) can be limitations towards listing for liver transplantation (LT). Our study evaluates the correlation of right ventricular systolic pressure (RVSP) and mean pulmonary artery pressure (mPAP) on transthoracic echocardiogram (TTE) compared to mPAP on right heart catheterization (RHC). METHODS We performed a retrospective review of 723 patients who underwent LT evaluation at our institution between 2012 and 2020. Our cohort consisted of patients with RVSP and mPAP measured on TTE. A Wald t-test and area under the curve analysis were used for statistical analyses. RESULTS Patients with higher mPAP values on TTE (N=33) did not correlate with mPAP ≥ 35 mmHg on RHC, while patients with higher RVSP values (N=147) on TTE were associated with mPAP ≥ 35 mmHg on RHC. The cutoff value of RVSP ≥ 48 mmHg on TTE was associated with mPAP ≥ 35 mmHg on RHC. CONCLUSIONS Our data suggest that RVSP compared to mPAP on TTE is a better indicator for mPAP ≥ 35 mmHg on RHC. RVSP can be used as a marker on echocardiography for identifying patients with a higher likelihood of PH being a barrier to LT listing.
Collapse
|
5
|
Lee MS, Wadia S, Yeghiazarians Y, Matthews R, White CJ, Herrmann HC, O’Donnell W, McPherson J, Leesar MA, Kreutz RP, Brandman D, Gupta A, Mandras S, Kandzari DE. Cardiology Assessment of Patients Undergoing Evaluation for Orthotopic Liver Transplantation. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100528. [PMID: 39132526 PMCID: PMC11308094 DOI: 10.1016/j.jscai.2022.100528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/29/2022] [Accepted: 10/14/2022] [Indexed: 08/13/2024]
Abstract
Orthotopic liver transplantation (OLT) is a viable treatment option for end-stage liver disease. Significant perioperative stress is placed on the cardiovascular system because of hemodynamic changes and the length of the operation. Diagnosis and treatment of cardiovascular disease before OLT are imperative to ensure favorable outcomes. Considerable variability exists among practitioners caring for these patients. Institutions tailor their protocols on the basis of local and historical practices, the preferences of the cardiologists, and the OLT team, and algorithms are not often revised or updated on the basis of the available evidence. In collaboration with cardiology and hepatology experts from leading OLT centers, we sought to examine the diagnostic cardiovascular workup of OLT candidates, including a review of the available literature on the diagnostic modalities used to screen cardiovascular disease before OLT. We advocate an emphasis on noninvasive methods to assess cardiovascular risk with reserved use of invasive risk stratification in select patients.
Collapse
Affiliation(s)
- Michael S. Lee
- Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, California
| | - Subeer Wadia
- Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, California
| | - Yerem Yeghiazarians
- Division of Cardiology, University of California, San Francisco Medical Center, San Francisco, California
| | - Ray Matthews
- Division of Cardiology, University of Southern California Medical Center, Los Angeles, California
| | | | - Howard C. Herrmann
- Division of Cardiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - William O’Donnell
- Division of Cardiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - John McPherson
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Massoud A. Leesar
- Division of Cardiology, University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | - Rolf P. Kreutz
- Division of Cardiovascular Medicine, Indiana University Health/Indiana University School of Medicine, Indianapolis, Indiana
| | - Danielle Brandman
- Division of Hepatology, University of California, San Francisco Medical Center, San Francisco, California
| | - Anuj Gupta
- Division of Cardiology, University of Maryland, Baltimore, Maryland
| | - Stacy Mandras
- Division of Cardiology, Advent Health, Orlando, Florida
| | | |
Collapse
|
6
|
Misra AC, Emamaullee J. CAQ Corner: Surgical evaluation for liver transplantation. Liver Transpl 2022; 28:1936-1943. [PMID: 35575000 PMCID: PMC9666671 DOI: 10.1002/lt.26505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/12/2022] [Accepted: 05/11/2022] [Indexed: 01/07/2023]
Abstract
The evaluation of a liver transplantation candidate is a complex and detailed process that in many cases must be done in an expedited manner because of the critically ill status of some patients with end-stage liver disease. It involves great effort from and the collaboration of multiple disciplines, and during the evaluation several studies and interventions are performed to assess and potentially prepare a patient for liver transplant. Here we review the liver transplantation evaluation from a surgical perspective.
Collapse
Affiliation(s)
- Asish C. Misra
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Juliet Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| |
Collapse
|
7
|
Dmytriiev D, Nazarchuk O, Melnychenko M, Levchenko B. Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications. Front Med (Lausanne) 2022; 9:935331. [PMID: 36262276 PMCID: PMC9573976 DOI: 10.3389/fmed.2022.935331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are increasingly used in the perioperative period around the world. The concept of goal-directed fluid therapy (GDT) is a key element of the ERAS protocols. Inadequate perioperative infusion therapy can lead to a number of complications, including the development of an infectious process, namely surgical site infections, pneumonia, urinary tract infections. Optimal infusion therapy is difficult to achieve with standard parameters (e.g., heart rate, blood pressure, central venous pressure), so there are various methods of monitoring central hemodynamics - from invasive, minimally invasive to non-invasive. The latter are increasingly used in clinical practice. The current evidence base shows that perioperative management, specifically the use of GDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient's optimal fluid balance. The manuscript presents the analytical data, which describe the benefits and basic principles of perioperative targeted infusion therapy based on central hemodynamic parameters to reduce the risk of complications.
Collapse
Affiliation(s)
- Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Oleksandr Nazarchuk
- Department of Microbiology, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Mykola Melnychenko
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Bohdan Levchenko
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| |
Collapse
|
8
|
Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
Collapse
Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| |
Collapse
|
9
|
Han S, Park J, Hong SH, Park CS, Choi J, Chae MS. Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view. Anesth Pain Med (Seoul) 2022; 17:132-144. [PMID: 35538654 PMCID: PMC9091670 DOI: 10.17085/apm.22132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/19/2022] Open
Abstract
Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.
Collapse
Affiliation(s)
- Sangbin Han
- Department of Emergency Medicine, Cheongyang Health Center County Hospital, Cheongyang, Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jongho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Corresponding author Min Suk Chae, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: 82-2-2258-6150 Fax: 82-2-537-1951 E-mail:
| |
Collapse
|
10
|
Jose A, Shah SA, Anwar N, Jones CR, Sherman KE, Elwing JM. Pulmonary Vascular Resistance Predicts Mortality and Graft Failure in Transplantation Patients With Portopulmonary Hypertension. Liver Transpl 2021; 27:1811-1823. [PMID: 33964116 PMCID: PMC8573056 DOI: 10.1002/lt.26091] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
Portopulmonary hypertension (POPH) is a pulmonary vascular disease associated with significant morbidity and mortality in those with liver disease, conferring a higher mortality in patients awaiting liver transplantation (LT). Although not a transplant indication, patients with POPH can experience significant clinical improvement following LT, and those maintaining a mean pulmonary artery pressure (MPAP) <35mm Hg and a pulmonary vascular resistance (PVR) <5 Woods units (WU) are granted additional listing points to expedite LT. The effect of POPH on posttransplant outcomes such as mortality and graft failure, however, is not well defined. We performed a retrospective cohort study of the US Organ Procurement and Transplantation Network database of all adult patients who underwent LT between January 1, 2006, and December 1, 2020. Using adjusted accelerated failure time models, we examined the relationship between a diagnosis of POPH and outcomes following LT and the relationship between pre-LT hemodynamics and post-LT survival (alive with a functioning graft) in patients with POPH. Compared with those undergoing transplants without exception points, patients with POPH had comparable post-LT survival rates but were significantly more likely to have graft failure. Both pre-LT MPAP and PVR predicted post-LT survival in POPH, with a pre-LT PVR of ≥1.6 WU, more than doubling the hazard for mortality (death or a nonfunctioning graft; coefficient, 2.01; standard error, 0.85; hazard ratio, 2.21; P = 0.02). POPH may confer a significantly higher risk of post-LT graft failure compared with patients with cirrhosis without POPH, and a pre-LT PVR of ≥1.6 WU may predict post-LT survival. Further investigation into the relationship between pre-LT hemodynamics, right ventricular function, and post-LT outcomes of mortality and graft failure in POPH is needed.
Collapse
Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
11
|
Lee SA, Hyun J, Yoon YI, Park SY, Lee JS, Kim DH, Song GW, Kim KH, Moon DB, Song JG, Hwang GS, Lee SG, Song JM. Clinical impact of mild to moderate pulmonary hypertension in living-donor liver transplantation. Transpl Int 2021; 34:1150-1160. [PMID: 33811394 DOI: 10.1111/tri.13875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/26/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022]
Abstract
Severe pulmonary hypertension (PHT) is a contraindication to liver transplantation (LT); however, the prognostic implication of mild to moderate PHT in living-donor LT (LDLT) is unknown. The study cohort retrospectively included 1307 patients with liver cirrhosis who underwent LDLT. PHT was defined as a mean pulmonary artery pressure (PAP) of ≥25 mmHg, measured intraoperatively just before surgery. The primary endpoint was graft failure within 1 year after LDLT, including retransplantation or death from any cause. The secondary endpoints were in-hospital adverse events. In the overall cohort, the median Model for End-stage Liver Disease-Sodium (MELD-Na) score was 19, and 100 patients (7.7%) showed PHT. During 1-year follow-up, graft failure occurred in 94 patients (7.2%). Patients with PHT had lower 1-year graft survival (86% vs. 93.4%, P = 0.005) and survival rates (87% vs. 93.6%, P = 0.011). Mean PAP was associated with a high risk of in-hospital adverse events and 1-year graft failure. Adding the mean PAP to the clinical risk model improved the risk prediction. In conclusion, mild to moderate PHT was associated with higher risks of 1-year graft failure and in-hospital events, including mortality after LDLT in patients with liver cirrhosis. Intraoperative mean PAP can help predict the early clinical outcomes after LDLT.
Collapse
Affiliation(s)
- Seung-Ah Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junho Hyun
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Department of Hepato-biliary and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seo-Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hee Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Hepato-biliary and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Department of Hepato-biliary and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Department of Hepato-biliary and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Hepato-biliary and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong-Min Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Sindwani G, Arora MK, Dhir A, Pamecha V. Unanticipated severe pulmonary hypertension in a patient undergoing living donor liver transplant - Role of milrinone and transesophageal echocardiography. Indian J Anaesth 2021; 65:S53-S55. [PMID: 33814593 PMCID: PMC7993036 DOI: 10.4103/ija.ija_833_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/27/2020] [Accepted: 01/12/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | - Achal Dhir
- Programme Director, Liver Transplant Anaesthesia (Department of Anaesthesia and Perioperative Medicine), Western University, London, Ontario, Canada
| | | |
Collapse
|
13
|
Smeltz AM, Kumar PA, Arora H. Anesthesia for Combined Heart and Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:3350-3361. [PMID: 33384228 DOI: 10.1053/j.jvca.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 01/23/2023]
Abstract
A heart or liver transplantation procedure performed in isolation itself presents multiple challenges for the perioperative team. Accordingly, combining both transplants yields a vastly more complicated surgery, with many unique multisystem and multidisciplinary considerations. Although combined heart and liver transplantations are being performed with increasing frequency, nationwide experience is relatively limited at most institutions. The aim of this review is to discuss the perioperative challenges presented to the anesthesiology teams and provide evidence-based guidance for the management of these daunting procedures.
Collapse
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
14
|
Navarro-Vergara DI, Roldan-Valadez E, Cueto-Robledo G, Jurado-Hernandez MY. Portopulmonary Hypertension: Prevalence, Clinical and Hemodynamic Features. Curr Probl Cardiol 2020; 46:100747. [PMID: 33248724 DOI: 10.1016/j.cpcardiol.2020.100747] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 02/05/2023]
Abstract
Portopulmonary hypertension (PoPH) is a vascular complication of portal hypertension. This study aims to identify the prevalence and analyzing the clinical and hemodynamic features of patients with PoPH from a cohort of pulmonary arterial hypertension (PAH) patients. A retrospective transversal descriptive and analytical study. Patients with PoPH taken from a PAH cohort. We compare with those reported in the literature. We found prevalence of 6.1% of 244 consecutive patients with PAH, 11 females and 4 males. The mean age was 62 years and the main etiology of portal hypertension was primary biliary cirrhosis. Statistical differences were found in mean pulmonary arterial pressure, pulmonary vascular resistance, right atrial pressure; we found levels lower than reported. We found significant differences in clinical and hemodynamic characteristics such as older age and hemodynamic parameters of less severity in the group of patients analyzed compared with reported data.
Collapse
|
15
|
Singh SA, Ashraf H, Subramanian R, Krishnan GA, Pandey V, Gupta S. Living donor liver transplantation in a patient with severe portopulmonary hypertension. Indian J Anaesth 2020; 64:153-155. [PMID: 32139937 PMCID: PMC7017663 DOI: 10.4103/ija.ija_512_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/29/2019] [Accepted: 12/03/2019] [Indexed: 01/24/2023] Open
Affiliation(s)
- Shweta A Singh
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Hashir Ashraf
- Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Rajkumar Subramanian
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Gopi A Krishnan
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Vijaykant Pandey
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant Surgery, CLBS, Max Saket Hospital, Saket, New Delhi, India
| |
Collapse
|
16
|
Habash F, Gurram P, Almomani A, Duarte A, Hakeem A, Vallurupalli S, Bhatti S. Correlation between Echocardiographic Pulmonary Artery Pressure Estimates and Right Heart Catheterization Measurement in Liver Transplant Candidates. J Cardiovasc Imaging 2018; 26:75-84. [PMID: 29971269 PMCID: PMC6024829 DOI: 10.4250/jcvi.2018.26.e2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/13/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Patients undergoing liver transplant have worse outcomes in the presence of pulmonary hypertension. Correlation between echocardiography and catheterization derived pressures in this population is not well studied. Our study's aim is to show the relationship between pulmonary artery systolic pressure derived from transthoracic echo (ePASP) with pulmonary artery systolic pressure measured during right heart catheterization (cPASP). METHODS Single center retrospective study, patients being evaluated for liver transplant (n = 31) who had an interpretable Doppler signal for ePASP and had right heart catheterization (RHC) measurements within 3 months constituted the study group. Control group (n = 49) consisted of patients who did not have liver disease. RESULTS There was modest correlation between ePASP and cPASP (R = 0.58, p < 0.001) in LT candidates (n = 31) compared with the control group (R = 0.74, p < 0.001, n = 49). The 95% limits of agreement by Bland-Altman analysis ranged from +33.6 mmHg to -21.7 mmHg. Using receiver operating characteristic analysis, ePASP cut-off > 47 mmHg was 59% sensitive and 78% specific to diagnose pulmonary artery (PA) hypertension (mean PA pressure > 25 mmHg) in the LT candidates, while a similar cutoff performed well in the control group (cutoff > 43 mmHg, n = 47, 91% sensitive, 100% specific). CONCLUSIONS Compared with other disease states, ePASP correlates modestly with cPASP in patients with advanced liver disease. A higher ePASP cutoff should be used to screen for pulmonary hypertension. A multi-center prospective study with simultaneous transthoracic echocardiography and RHC measurements is required to determine the best cut-off in this population.
Collapse
Affiliation(s)
- Fuad Habash
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Pooja Gurram
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ahmed Almomani
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Andres Duarte
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Abdul Hakeem
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Srikanth Vallurupalli
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sabha Bhatti
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| |
Collapse
|
17
|
Herborn J, Lewis C, De Wolf A. Liver Transplantation: Perioperative Care and Update on Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
18
|
Shim CY. Issues on Estimated Pulmonary Artery Pressure in Liver Transplant Candidates. J Cardiovasc Imaging 2018; 26:61-62. [PMID: 29971266 PMCID: PMC6024838 DOI: 10.4250/jcvi.2018.26.e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Indexed: 11/22/2022] Open
Affiliation(s)
- Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
19
|
Yilmaz KC, Ciftci O, Akgun AN, Muderrisoglu H, Boyacioglu S, Haberal AN, Moray G, Haberal M. Relation of Preoperative and Postoperative Echocardiographic Parameters With Rejection and Mortality in Liver Transplant Patients. EXP CLIN TRANSPLANT 2018; 18:210-214. [PMID: 29790458 DOI: 10.6002/ect.2017.0174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Survival in liver transplant after end-stage liver disease is associated with major cardiac functions. In a significant number of patients with end-stage liver disease, cardiac dysfunctions may be observed, which can include high-output heart failure, cardiac valve disease, and pulmonary venous and arterial hypertension. All of these affect perioperative survival. The aim of our study was to determine whether preoperative and postoperative echocardiographic parameters, specifically right heart-related tricuspid regurgitation, estimated systolic pulmonary arterial pressure, and tricuspid annular plane systolic excursion, are associated with rejection and mortality in liver transplant patients. MATERIALS AND METHODS Adult patients (> 18 years old) who underwent liver transplant at our center between January 2011 and March 2017 were included in the study, with 64 patients retrospectively screened. The echocardiographic images that were taken immediately before and immediately after liver transplant were evaluated. The patients were divided into 2 groups according to rejection data and mortality. All parameters were analyzed for both variables. RESULTS For the 24 patients with liver rejection and 40 patients without liver rejection, there were no statistically significant differences in terms of demographic data, echocardiographic parameters, and laboratory data. However, when patients were evaluated according to survival, there was a statistically significant difference between these 2 groups concerning the echocardiography parameters of systolic pulmonary arterial pressure (P = .005), tricuspid annular plane systolic excursion (P = .001), and postoperative right ventricular width (P = .01). CONCLUSIONS Echocardiography, being a simple and easily accessible technique that is reliable in excluding pulmonary hypertension diagnosis, can be used as a guide in the evaluation of right ventricular function and tricuspid regurgitation, particularly in patients who are not hemodynamically stable before and after liver transplant.
Collapse
Affiliation(s)
- Kerem Can Yilmaz
- >From the Cardiology Department, Baskent University Faculty of Medicine, Ankara, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Bubnov RV, Drahulian MV, Buchek PV, Gulko TP. High regenerative capacity of the liver and irreversible injury of male reproductive system in carbon tetrachloride-induced liver fibrosis rat model. EPMA J 2018; 9:59-75. [PMID: 29515688 PMCID: PMC5833895 DOI: 10.1007/s13167-017-0115-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver fibrosis (LF) is a chronic disease, associated with many collateral diseases including reproductive dysfunction. Although the normal liver has a large regenerative capacity the complications of LF could be severe and irreversible. Hormone and sex-related issues of LF development and interactions with male reproductive have not been finally studied. The aim was to study the reproductive function of male rats in experimental CCl4-induced liver fibrosis rat model, and the capability for restoration of both the liver and male reproduction system. MATERIALS Studies were conducted on 20 3-month old Wistar male rats. The experimental animals were injected with freshly prepared 50% olive oil solution of carbohydrate tetrachloride (CCl4). On the 8th week after injection we noted the manifestations of liver fibrosis. The rats were left to self-healing of the liver for 8 weeks. All male rats underwent ultrasound and biopsy of the liver and testes on the 8th and 16th weeks. The male rats were mated with healthy females before CCl4 injection, after modeling LF on the 8th week, and after self-healing of the liver. Pregnancy was monitored on ultrasound. RESULTS On the 8th week of experiment we observed ultrasound manifestation of advanced liver fibrosis, including hepatosplenomegaly, portal hypertension. Ultrasound exam of the rat testes showed testicular degeneration, hydrocele, fibrosis, scarring, petrifications, size reduction, and restriction of testicular descent; testes size decreased from 1.24 ± 0.62 ml to 0.61 ± 0.13, p < 0.01. Liver histology showed granular dystrophy of hepatocytes, necrotic areas, lipid inclusions in parenchyma. Rats with liver fibrosis demonstrated severe injury of the reproductive system and altering of fertility: the offspring of male rats with advanced LF was 4.71 ± 0.53 born alive vs 9.55 ± 0.47 born from mating with healthy males, p < 0.001. Eight weeks after last CCl4 injection, we revealed signs of liver regeneration, significant recovery of its structure. The ALT and AST levels significantly decreased and reached background measurements. As a result of the second interbreeding after liver self-healing no significant difference was found vs previous mating. CONCLUSION Carbohydrate tetrachloride induces injury of liver parenchyma evoking fast and severe liver fibrosis, and is associated with irreversible structural and functional changes in testes, reducing fertility, decreasing potential pregnancy rate, and affecting its development. Liver showed high potential to regenerate, however the self-restoring after liver fibrosis was not accompanied with recovery of the reproductive system.
Collapse
Affiliation(s)
- Rostyslav V. Bubnov
- Zabolotny Institute of Microbiology and Virology, National Academy of Sciences of Ukraine, Zabolotny Str., 154, Kyiv, 03143 Ukraine
- Clinical Hospital ‘Pheophania’ of State Affairs Department, Zabolotny str., 21, Kyiv, 03143 Ukraine
| | - Maria V. Drahulian
- Institute of Molecular Biology and Genetics, National Academy of Sciences of Ukraine, Zabolotny str., 150, Kyiv, 03143 Ukraine
| | - Polina V. Buchek
- Institute of Molecular Biology and Genetics, National Academy of Sciences of Ukraine, Zabolotny str., 150, Kyiv, 03143 Ukraine
| | - Tamara P. Gulko
- Institute of Molecular Biology and Genetics, National Academy of Sciences of Ukraine, Zabolotny str., 150, Kyiv, 03143 Ukraine
| |
Collapse
|
21
|
Zardi EM, Zardi DM, Giorgi C, Chin D, Dobrina A. Portopulmonary hypertension and hepatorenal syndrome. Two faces of the same coin. Eur J Intern Med 2017; 43:22-27. [PMID: 28583409 DOI: 10.1016/j.ejim.2017.05.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/13/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023]
Abstract
Portopulmonary hypertension and hepatorenal syndrome are both severe local hypertensive complications of liver cirrhosis and portal hypertension. Both are characterized by vasoconstrictive manifestations regarding pulmonary and renal vascular network, respectively. This review addresses the mechanisms underlying the development of vasoconstriction that leads to local vascular hypertension in the lung and in the kidney with the result of organ dysfunction. Potential therapeutic options are available for the management of these two syndromes as a bridge for liver transplantation; clinical efficacy depends in part on the time and rapidity of intervention and in part on how serious the chain of events is that has triggered the entire vasoconstrictive process.
Collapse
Affiliation(s)
- Enrico Maria Zardi
- Internal Medicine Department of Campus Bio-Medico University, Rome, Italy.
| | - Domenico Maria Zardi
- Interventional Cardiology Department of S. Andrea Hospital, University La Sapienza of Rome, Italy
| | - Chiara Giorgi
- Radiology Department, S. Maria della Misericordia Hospital, Urbino, Italy
| | - Diana Chin
- Interventional Cardiology Department San Camillo Hospital, Rome, Italy
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| |
Collapse
|
22
|
Liu H, Jayakumar S, Traboulsi M, Lee SS. Cirrhotic cardiomyopathy: Implications for liver transplantation. Liver Transpl 2017; 23:826-835. [PMID: 28407402 DOI: 10.1002/lt.24768] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/23/2017] [Indexed: 12/12/2022]
Abstract
The majority of patients on a waiting list for liver transplantation have end-stage liver disease. Because of the marked peripheral vasodilatation of end-stage cirrhosis that masks a latent myocardial dysfunction, cardiac abnormalities in the resting state are usually subclinical and escape the attention of physicians. However, when challenged, the systolic and diastolic contractile responses are attenuated. In addition to these contractile abnormalities, morphological changes, such as enlargement or hypertrophy of cardiac chambers, and electrophysiological repolarization changes, including a prolonged QT interval, can be observed. The constellation of these cardiac abnormalities is termed cirrhotic cardiomyopathy. Liver transplantation induces significant cardiovascular stress. Clamping of the inferior vena cava and portal vein, hemorrhage and blood/volume infusion, and ischemia/reperfusion all cause hemodynamic fluctuation. The changing cardiac preload and afterload status increases the cardiac workload, and thus, the previously subclinical ventricular dysfunction may manifest as overt heart failure during the operative and perioperative periods. Cardiac dysfunction contributes to morbidity and mortality associated with liver transplantation. Cardiovascular events are the third leading cause of death in liver recipients. However, because liver transplantation is the only definitive treatment for end-stage liver failure and also appears to reverse cardiac abnormalities, it is important to understand the challenges of the heart in liver transplantation. This review focuses on cardiac status before, during, and after liver transplantation. Liver Transplantation 23 826-835 2017 AASLD.
Collapse
Affiliation(s)
- Hongqun Liu
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Saumya Jayakumar
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mouhieddin Traboulsi
- Division of Cardiology and Libin Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Samuel S Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| |
Collapse
|
23
|
Rodríguez-Almendros N, Toapanta-Yanchapaxi LN, Aguirre Valadez J, Espinola Zavaleta N, Muñoz-Martínez SG, García-Juárez I. [Portopulmonary hypertension: Updated review]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 88:25-38. [PMID: 27986561 DOI: 10.1016/j.acmx.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022] Open
Abstract
Portopulmonary hypertension (PPH) is a rare condition worldwide, although epidemiological data are unknown in Mexico. However, chronic liver diseases are very prevalent in Mexico. PPH is the 4th subtype in frequency in the group of pulmonary arterial hypertension. Its diagnosis is made within 2 scenarios: patients with suspected pulmonary hypertension and candidates for orthotopic liver transplantation (OLT). Both echocardiogram and a right cardiac catheterisation are crucial for diagnosis in both cases. PPH is a challenge for OLT, since it can significantly increase perioperative mortality. The use of specific therapy is the cornerstone of this disease, as a measure to improve the outcome of those who become candidates for OLT with moderate to severe PPH. It is important to recognise that PPH can be a contraindication to OLT. The role of lung-liver transplantation or heart-lung-liver transplantation as a measure to heal pulmonary vascular disease in patients with PPH is still uncertain.
Collapse
Affiliation(s)
- Nielzer Rodríguez-Almendros
- Departamento de Hipertensión Pulmonar y Función Ventricular Derecha, UMAE Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México, D.F., México
| | - Liz N Toapanta-Yanchapaxi
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Jonathan Aguirre Valadez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Nilda Espinola Zavaleta
- Departamento de Ecocardiografia, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Sergio G Muñoz-Martínez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Ignacio García-Juárez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| |
Collapse
|
24
|
Surani SR, Mendez Y, Anjum H, Varon J. Pulmonary complications of hepatic diseases. World J Gastroenterol 2016; 22:6008-15. [PMID: 27468192 PMCID: PMC4948262 DOI: 10.3748/wjg.v22.i26.6008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/01/2016] [Accepted: 05/21/2016] [Indexed: 02/06/2023] Open
Abstract
Severe chronic liver disease (CLD) may result from portal hypertension, hepatocellular failure or the combination of both. Some of these patients may develop pulmonary complications independent from any pulmonary pathology that they may have. Among them the hepatopulmonary syndrome (HPS), portopulmonary hypertension (PPH) and hepatic hydrothorax (HH) are described in detail in this literature review. HPS is encountered in approximately 15% to 30% of the patients and its presence is associated with increase in mortality and also requires liver transplantation in many cases. PPH has been reported among 4%-8% of the patient with CLD who have undergone liver transplantation. The HH is another entity, which has the prevalence rate of 5% to 6% and is associated in the absence of cardiopulmonary disease. These clinical syndromes occur in similar pathophysiologic environments. Most treatment modalities work as temporizing measures. The ultimate treatment of choice is liver transplant. This clinical review provides basic concepts; pathophysiology and clinical presentation that will allow the clinician to better understand these potentially life-threatening complications. This article will review up-to-date information on the pathophysiology, clinical features and the treatment of the pulmonary complications among liver disease patients.
Collapse
|