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Role of Baseline Echocardiography in Preoperative Management of Liver Transplant Candidates

      We read the recent report regarding the role of echocardiography in the preoperative evaluation for liver transplantation (LT).
      • Harinstein M.E.
      • Iyer S.
      • Mathier M.A.
      • Flaherty J.D.
      • Fontes D.
      • Planinsic R.N.
      • Edelman K.
      • Katz W.E.
      • Lopez-Candales A.
      Role of baseline echocardiography in the preoperative management of liver transplant candidates.
      We would like to share some thoughts and concerns regarding the importance of the development of lung vascular disorders in the setting of liver disease or portal hypertension, in particular, the development of portopulmonary hypertension. Right heart catheterization (RHC) represents the reference standard for the diagnosis of portopulmonary hypertension.
      • Porres-Aguilar M.
      • Altamirano J.T.
      • Torre-Delgadillo A.
      • Charlton M.R.
      • Duarte-Rojo A.
      Portopulmonary hypertension and hepatopulmonary syndrome: a clinician-oriented overview.
      Despite the poor agreement between echocardiographic and RHC parameters,
      • Krowka M.J.
      • Swanson K.L.
      • Frantz R.P.
      • McGoon M.D.
      • Wiesner R.H.
      Portopulmonary hypertension: results from a 10-year screening algorithm.
      LT programs have successfully used the right ventricular systolic pressure (RVSP) to identify patients needing RHC; however, the cutoff values of RVSP vary depending on in which center the patient is being evaluated for LT (e.g., Mayo Clinic, University of California, San Francisco, Medical Center). Because of these factors, we would like to raise the following questions: (1) what was your RVSP cutoff value to strongly consider RHC?; (2) what was the percentage of patients who underwent diagnostic RHC?; and, finally, (3) what proportion of patients during RHC experienced an increased pulmonary blood flow phenomenon (e.g., hyperdynamic state due to fluid overload with normal or low pulmonary vascular resistance) versus true vaso-occlusive arteriopathy? We understand that an important limitation of your study was the lack on RHC. We believe that future portopulmonary hypertension guidelines should focus on defining the RVSP cutoff values and other key echocardiographic aspects to delineate which pre-LT patients need RHC.
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      References

        • Harinstein M.E.
        • Iyer S.
        • Mathier M.A.
        • Flaherty J.D.
        • Fontes D.
        • Planinsic R.N.
        • Edelman K.
        • Katz W.E.
        • Lopez-Candales A.
        Role of baseline echocardiography in the preoperative management of liver transplant candidates.
        Am J Cardiol. 2012; 110: 1852-1855
        • Porres-Aguilar M.
        • Altamirano J.T.
        • Torre-Delgadillo A.
        • Charlton M.R.
        • Duarte-Rojo A.
        Portopulmonary hypertension and hepatopulmonary syndrome: a clinician-oriented overview.
        Eur Respir Rev. 2012; 21: 223-233
        • Krowka M.J.
        • Swanson K.L.
        • Frantz R.P.
        • McGoon M.D.
        • Wiesner R.H.
        Portopulmonary hypertension: results from a 10-year screening algorithm.
        Hepatology. 2006; 44: 1502-1510

      Linked Article

      • Role of Baseline Echocardiography in the Preoperative Management of Liver Transplant Candidates
        American Journal of CardiologyVol. 110Issue 12
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          Liver transplantation (LT) has not traditionally been offered to patients with intracardiac shunts (ICSs) or pulmonary hypertension (PH). There is a paucity of data regarding cardiac structural characteristics in LT candidates. We examined echocardiographic characteristics and their role in managing LT candidates diagnosed with ICS and PH. We identified 502 consecutive patients (318 men, mean age 55 ± 11 years) who underwent LT and had preoperative echocardiogram. Demographics, cardiovascular risk factors, and echocardiographic variables were recorded and data were analyzed for end-stage liver disease diagnosis.
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      • Reply
        American Journal of CardiologyVol. 111Issue 8
        • Preview
          We appreciate the comments and viewpoints of Dr. Porres-Aguilar and Dr. Mukherjee regarding our article on the role of baseline echocardiography in the preoperative management of liver transplant candidates.1 We agree with their assessment that right heart catheterization (RHC) is the gold standard for diagnosis of portopulmonary hypertension and that it correlates variably with echocardiography in some patients. In our article, we observed that patients with pulmonary hypertension, as diagnosed by echocardiography, did not have worse outcomes after liver transplantation.
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