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Predictive Value of Dobutamine Stress Perfusion Echocardiography in Contemporary End-Stage Liver Disease
Bipul Baibhav1, Chetaj A Mahabir1, Feng Xie1
1University of Nebraska Medical Center, Omaha, NE.
Insights
Dobutamine stress perfusion echocardiography identifies microvascular dysfunction, a key predictor of cardiovascular events after liver transplantation. This test improves risk assessment for patients undergoing liver transplant surgery.
Area of Science:
- Cardiology
- Hepatology
- Transplant Surgery
Background:
- Liver transplantation (LT) requires sensitive cardiac risk assessment for occult coronary artery disease and functional abnormalities.
- Dobutamine stress perfusion echocardiography (DSPE) assesses regional systolic/diastolic function and microvascular perfusion (MVP).
Purpose of the Study:
- To examine the incremental value of DSPE in assessing cardiac risk in liver transplant candidates.
Main Methods:
- Evaluated 296 adult LT patients (2008-2014) with preserved systolic function.
- Assessed cardiovascular death, myocardial infarction, and arrhythmias as primary outcomes.
- Utilized DSPE to identify abnormal MVP and diastolic dysfunction.
Main Results:
- Abnormal MVP detected in 6% of patients; diastolic dysfunction in 94%.
- Patients with abnormal MVP had a 7-fold higher risk of post-LT cardiovascular events.
- Abnormal MVP was the sole independent predictor of adverse cardiovascular outcomes (HR 7.7, P=0.004).
Conclusions:
- Stress MVP assessments are highly predictive of cardiovascular outcomes in LT candidates.
- DSPE enhances cardiac risk stratification for liver transplant recipients.
Background:
The assessment of cardiac risk in contemporary liver transplantation (LT) has required more sensitive testing for the detection of occult coronary artery disease as well as microvascular and functional cardiac abnormalities. Because dobutamine stress perfusion echocardiography provides an assessment of both regional systolic and diastolic function as well as microvascular perfusion (MVP), we sought to examine its incremental value in this setting.
Methods And Results:
We evaluated the predictive value of dobutamine stress perfusion echocardiography in 296 adult patients with end-stage liver disease and preserved systolic function who underwent LT between 2008 and 2014. The primary outcome was cardiovascular death, nonfatal myocardial infarction, and/or sustained ventricular arrhythmias following LT. The main causes of liver failure were hepatitis C (25%) and nonalcoholic fatty liver disease (13%). Abnormal MVP during stress was observed in 18 patients (6%), whereas diastolic dysfunction was present in 109 patients (94 grade 1, 15 grade 2). Half of the patients (7 of 14) referred for angiography with abnormal MVP had significant epicardial disease by angiography, and these patients were revascularized prior to LT. Despite these interventions, the primary outcome still occurred in 9 patients (3%). Patients with abnormal MVP during dobutamine stress perfusion echocardiography had a 7-fold higher risk of a cardiovascular event following LT. Cox proportional hazards modeling examining clinical variables, left ventricular ejection fraction, diastolic function, and stress-induced wall motion abnormalities or MVP defects demonstrated that abnormal MVP was the only independent predictor of the primary outcome (P=0.004; hazard ratio 7.7).
Conclusions:
Stress MVP assessments are highly predictive of cardiovascular outcome in current LT candidates.
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