Saline Contrast Echocardiography in Patients With Hepatopulmonary Syndrome Awaiting Liver Transplantation

doi:10.1016/j.echo.2008.09.020

Journal of the American Society of Echocardiography

Volume 22, Issue 1, January 2009, Pages 89-94

https://doi.org/10.1016/j.echo.2008.09.020 Get rights and content

Background

Patients with hepatopulmonary syndrome (HPS) with end-stage liver disease (ESLD) have higher cardiorespiratory mortality than those without. The aims of this study were to determine whether echocardiography could distinguish patients with ESLD with and without HPS and whether the diagnosis of HPS by contrast echocardiography (CE) was altered by the performance of the test in a supine or standing position.

Methods

Subjects were recruited prospectively from patients with end-stage liver disease undergoing assessment for liver transplantation. Hepatopulmonary syndrome was diagnosed on the basis of arterial blood gas analysis, lung function testing and agitated saline contrast echocardiography in the absence of primary cardiac or pulmonary disease. Bubble contrast injections were performed supine or standing in a randomised order and read by a blinded observer.

Results

CE showed late right-to-left shunting in 13 of 50 consecutive patients with cirrhosis (26%). Eight patients (16%) had definite diagnoses of HPS. CE in the standing position consistently increased both the number and the size of shunts compared with supine injection. CE detected intrapulmonary shunting before a change in arterial blood gases. Standard echocardiographic parameters did not distinguish between those with and without HPS.

Conclusion

This study suggests that screening for HPS in patients with advanced cirrhosis should be done using CE with patients in the upright position.

Section snippets

Patient Selection

Fifty consecutive patients with cirrhosis of 85 potential candidates were recruited prospectively over a 6-month period from elective admissions to the Liver Unit at the University Hospital Birmingham for LT assessment. Liver cirrhosis was diagnosed from clinical, biochemical, and ultrasonic findings. Hepatic histology was obtained only in 12 patients in whom etiology was unknown. The degree of liver dysfunction was graded according to the Child-Pugh-Turcotte (CPT) classification. The mortality

Results

Fifty patients with cirrhosis (60% men; median age, 53 years) of a potential 85 were studied. The 35 patients who were not included either refused consent (n = 30) or had inadequate acoustic windows for CE (n = 5). Demographic data according to positive and negative results on CE are shown in Table 1. Patients with positive results on CE had higher CPT scores than those with negative results on CE. No difference was found in MELD score or in the etiology of cirrhosis. The frequencies of smoking

Discussion

The reported prevalence of HPS detected by transthoracic CE varies widely (5%-47%), and definitive diagnosis of HPS ranges between 4% and 29% among patients with cirrhosis because of the differences in diagnostic criteria adopted.8, 16, 17, 18, 19, 20 HPS has been diagnosed with a higher prevalence when diagnosis has relied on CE alone and less frequently according to changes in ABG or PFT. Our study suggests that smaller intrapulmonary shunts are detected before a change in ABG occurs, which

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Role of Quantitation of Saline Bubble Studies in Patients with Liver Cirrhosis
2023, Ultrasound in Medicine and Biology
Microbubble contrast echocardiography with a late positive signal enables the detection of intrapulmonary vascular dilation, including hepatopulmonary syndrome, in patients with end-stage liver disease. We assessed the relationship between the severity of bubble study and clinical outcome.
We retrospectively analyzed 163 consecutive patients with liver cirrhosis who underwent an echocardiogram with bubble study from 2018 to 2021. Patients who were diagnosed with a late positive signal were divided into three groups: grade 1 (1–9 bubbles), grade 2 (10–30 bubbles) and grade 3 (>30 bubbles).
Fifty-six percent of the patients had a late positive bubble study (grade 1: 31%, grade 2: 23%, grade 3: 46%). Patients with grade 3 had a significantly higher international normalized ratio, model for end-stage liver disease score and Child–Pugh score and a lower peripheral oxygen saturation compared with patients with a negative study. In patients undergoing liver transplant (LT), survival rates were similar among the groups (3-mo: >87%, 1-y: >87%, 2-y: >83%). However, survival rate was lower in grade 3 patients without LT (3-mo: 81%, 1-y: 64%, 2-y: 39%).
Patients with grade 3 had much worse mortality without LT compared with other groups. However, after LT, all grades had equal survival. Therefore, patients with grade 3 may be considered as higher priority for LT.
Clinical Impact of Intrapulmonary Vascular Dilatation in Candidates for Liver Transplant
2018, Chest
Intrapulmonary vascular dilatations (IPVD) frequently are detected in patients with liver disease by the delayed appearance of microbubbles at contrast-enhanced echocardiography. IPVD with an elevated alveolar-arterial (A-a) gradient define hepatopulmonary syndrome (HPS); however, the importance of IPVD in the absence of abnormal gas exchange is unknown. We aimed to determine the clinical impact of IPVD in patients with liver disease.
We performed a cross-sectional study within the Pulmonary Vascular Complications of Liver Disease 2 Study, a multicenter, prospective cohort study of patients being evaluated for liver transplant. We excluded patients with obstructive or restrictive lung disease, HPS, or intracardiac shunting. We compared patients with and those without IPVD.
Forty-six patients with IPVD and 81 patients without IPVD were included. Patients with IPVD were more likely to have autoimmune hepatitis and less likely to have cryptogenic cirrhosis and hepatocellular carcinoma. Patients with IPVD had higher Child-Pugh scores (6 [interquartile range (IQR), 5-7] vs 5 [IQR, 4-7]; P = .04), possibly higher Model for End-Stage Liver Disease scores (14.5 [IQR, 11.6-15.8] vs 12.2 [IQR, 9.4-15.5]; P = .06), higher PaO₂ levels (97.9 [IQR, 92.0-103.0] vs 89.0 [IQR, 82.0-96.9] mm Hg; P < .001), and lower A-a gradients (9.9 [IQR, 6.2-13.5] vs 14.9 [IQR, 9.0-21.8] mm Hg; P < .001). Symptoms and quality of life were similar between the groups.
Autoimmune hepatitis and increased liver disease severity were associated with the presence of IPVD, which was characterized by higher PaO₂ levels. Future studies to better characterize IPVD pathogenesis and the relationship of IPVD to HPS are warranted.
Do late bubbles correspond to early hepatopulmonary syndrome?
2017, Annals of Hepatology
Evaluation of Arteriovenous Shunting in Patients with End-Stage Liver Disease: Potential Role of Early Right Heart Catheterization
2015, Transplantation Proceedings
Citation Excerpt :
In patients with significant thrombocytopenia and/or significantly prolonged international normalized ratio, platelet infusions and/or fresh frozen plasma infusions, respectively, were given immediately before the procedure. RHC was performed on all patients, and ICE assessment was performed to evaluate anatomy and degree and direction of shunting with the use of standard protocols [9,13–15] using an 8-F ICE catheter with a 5–10-MHz multiple frequency transducer (Acunav; Siemens, Erlangen, Germany). ICE data collected included the presence or absence of a PFO, presence or absence of fenestration [16], and the presence or absence of IPS [17], which was detected with the use of selective right and left pulmonary artery (PA) injections of agitated saline solution (ICE bubble study).
In patients with end-stage liver disease (ESLD), the presence of hypoxemia suggests the presence of intrapulmonary oxygen shunting (IPS) and/or transatrial shunting. Early identification of each is imperative to avoid potentially fatal peritransplantation complications and appropriately prioritize patients for liver transplantation (LT). The aim of this work was to compare the sensitivity of transthoracic echocardiography (TTE) and right heart catheterization (RHC) with intracardiac echocardiography (ICE) for identifying the etiologies of resting hypoxemia in patients with ESLD being evaluated for LT.
Records of 28 patients with ESLD and resting hypoxemia who underwent TTE with bubble study and RHC/ICE were reviewed. Patients with a patent foramen ovale (PFO) were compared with non-PFO patients to determine diagnostic accuracy of TTE with bubble study versus RHC/ICE.
TTE with bubble study diagnosed PFO, IPS, and pulmonary hypertension (PH), respectively, with sensitivities of 46%, 41%, and 25% and specificities of 46%, 45%, and 80% compared with RHC/ICE. Although IPS detected by RHC/ICE was more common in patients without a PFO (92%), 5 patients with a PFO (33%) also had IPS (P = .002). Isolated PH was detected exclusively in patients with a PFO (5/15; 33%).
TTE with bubble study is neither sensitive nor specific to exclude a PFO in patients with ESLD. RHC/ICE is a safe and accurate diagnostic/interventional modality in this group of patients and is useful to diagnose other comorbidities, such as IPS and PH, that may coexist and contribute to resting hypoxemia.
Portopulmonary Hypertension and Hepatopulmonary Syndrome
2015, Transplantation of the Liver: Third Edition
Liver in cardiopulmonary disease
2013, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
If the bubbles appear in the left atrium after 3–6 cycles, it is highly suggestive of intrapulmonary shunting [18]. However, if the bubbles appear immediately in the left atrium then it is highly suggestive of intracardiac shunting [19]. In the MAA study, macroaggregated albumin is radiolabelled with technetium-99m and injected into a peripheral vein.
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are two fascinating and incompletely understood pulmonary vascular conditions seen in the setting of cirrhotic patients. Of the two HPS is more common and is primarily caused by pulmonary vasodilatation resulting in hypoxaemia and hyperdynamic circulation. PoPH is less common and conversely, pulmonary vasoconstriction and vascular remodelling occurs resulting in increased pulmonary vascular resistance. However, both conditions can co-exist and it is usually PoPH which develops in a patient with pre-existing HPS. Although these two pulmonary conditions are not common complications of chronic liver diseases, the treatment options are mainly limited to liver transplantation. Cirrhotic cardiomyopathy is closely related to haemodynamic changes in portal hypertension. The key features are normal cardiac pressures at rest, with reduced ability to compensate for physiological or iatrogenic stresses such as drug therapy or TIPSS. There is no effective therapy and outcomes after liver transplantation are variable.

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Saline Contrast Echocardiography in Patients With Hepatopulmonary Syndrome Awaiting Liver Transplantation

Background

Methods

Results

Conclusion

Section snippets

Patient Selection

Results

Discussion

J Hepatol

Liver Transpl

Clin Chest Med

Gastroenterology

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Hepatol

Chest

Am J Cardiol

Chest

Gastroenterology

Liver Transplant

Chest

Liver Transplant