Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

Antoine Addoumieh; Mouin S Abdallah; Jad A Ballout; Lucy Thuita; Allan Klein; Wael A Jaber; Reza Arsanjani; William Carey; David Majdalany

doi:10.1016/j.ahjo.2021.100026

Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

Am Heart J Plus. 2021 Jun 24:4:100026. doi: 10.1016/j.ahjo.2021.100026. eCollection 2021 Apr.

Authors

Antoine Addoumieh¹, Mouin S Abdallah¹, Jad A Ballout¹, Lucy Thuita², Allan Klein¹, Wael A Jaber¹, Reza Arsanjani³, William Carey⁴, David Majdalany³

Affiliations

¹ Heart and Vascular Institute, Cleveland Clinic Foundation, USA.
² Quantitative Health Science Department, Cleveland Clinic Foundation, USA.
³ Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA.
⁴ Digestive Disease Institute, Cleveland Clinic Foundation, USA.

Abstract

Introduction: Patients with end stage liver disease (ESLD) have a hyperdynamic state due to decreased systemic vascular resistance and increased cardiac output. Preoperative evaluation with dobutamine stress echocardiography (DSE) is used to risk-stratify patients prior to liver transplant. We sought to identify the impact of inducible left ventricular outflow tract obstruction (LVOTO) on DSE on post-operative liver transplant outcomes.

Methods: Patients with ESLD who underwent liver transplant at Cleveland Clinic between January 2007 and August 2016 were identified. Pre-operative DSE data, and post-operative intensive care unit (ICU) data were extracted. Patients with inducible LVOTO were compared to those without LVOTO.

Results: Of the 515 patients identified who underwent DSE prior to liver transplant, 165 (30%) were female, and 95 (18%) had LVOTO. There were no major differences in baseline characteristics between the two groups. In the LVOTO group, rest gradients were 10.8 ± 3 mm Hg while peak gradients were 90 ± 48.2 mm Hg. No significant differences in ICU length of stay or duration of mechanical ventilation between both groups were noted. There were 21 deaths at 30 days. There were 2 (2.1%) deaths in the LVOTO group, versus 19 (4.5%) deaths in the non LVOTO group (p = 0.28). Higher Model for End Stage Liver Disease (MELD) scores predicted longer duration of mechanical ventilation and ICU length of stay.

Conclusion: Inducible LVOTO on DSE does not adversely affect the short-term outcomes post liver transplant. Presence of inducible LVOTO should not be the mere reason to deny liver transplant among patients with ESLD.

Keywords: Cirrhosis of the liver; Dobutamine stress echocardiography; Dynamic left ventricular outflow tract obstruction; Echocardiography; End stage liver disease; Left ventricular outflow tract obstruction; Liver transplant evaluation; Model for End Stage Liver Disease; Orthotopic liver transplant; Stress imaging.