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Portopulmonary hypertension: Results from a 10-year screening algorithm

Authors

  • Michael J. Krowka,

    Corresponding author
    1. Divisions of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
    2. Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
    3. Liver Transplant Center, Mayo Clinic College of Medicine, Rochester, MN
    • Professor of Medicine, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905
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    • fax: 507-266-4372

  • Karen L. Swanson,

    1. Divisions of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
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  • Robert P. Frantz,

    1. Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, MN
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  • Michael D. McGoon,

    1. Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, MN
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  • Russell H. Wiesner

    1. Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
    2. Liver Transplant Center, Mayo Clinic College of Medicine, Rochester, MN
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  • Presented in abstract form at the 2005 International Liver Transplant Society Meeting, Los Angeles, CA.

  • Potential conflict of interest: Dr. Krowka is a consultant for and received grants from Cotherix. Dr. McGoon is a consultant for and received grants from Cotherix, Medtronic, and Myogen. He is a consultant for Actelion.

Abstract

Portopulmonary hypertension (POPH) is the elevation of pulmonary artery pressure due to increased resistance to pulmonary blood flow in the setting of portal hypertension. Increased mortality has occurred with attempted liver transplantation in such patients and thus, screening for POPH is advised. We examined the relationship between screening echocardiography and right heart catheterization determinations of pressure, flow, volume, and resistance. A prospective, echocardiography–catheterization algorithm was followed from 1996 to 2005. Consecutive transplantation candidates underwent Doppler echocardiography to determine right ventricular systolic pressure (RVSP). Of 1,235 patients, 101 with RVSP >50 mm Hg underwent catheterization to measure mean pulmonary artery pressure (MPAP), flow via cardiac output (CO), central volume via pulmonary artery occlusion pressure (PAOP), and resistance via calculated pulmonary vascular resistance (PVR). Bland-Altman analysis suggested marked discordance between echocardiography-derived RVSP and catheterization results. All-cause pulmonary hypertension (MPAP >25 mm Hg) was documented in 90/101 (90%) patients. Using current pressure and resistance diagnostic guidelines (MPAP >25 mm Hg, PVR ≥240 dynes/s/cm−5), POPH was documented in 66/101 (65%) patients. Elevated MPAP was due to increased CO and/or PAOP in 35/101 (35%) patients with normal resistance (PVR <240 dynes/s/cm−5). The transpulmonary gradient (MPAP–PAOP) further characterized POPH in the presence of increased volume. Model for end stage liver disease (MELD) scores correlated poorly with MPAP and PVR. In conclusion, right heart catheterization is necessary to confirm POPH and frequently identifies other reasons for pulmonary hypertension (e.g., high flow and increased central volume) in liver transplantation candidates. Severity of POPH correlates poorly with MELD scores. (HEPATOLOGY 2006;44:1502–1510.)

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