Predictors Of Right Heart Failure Post Liver Transplant

Abstract

Background Cardiac complications in liver cirrhosis are associated with increased mortality following liver transplant. Pre-transplant guidelines recommend risk stratification with 2D and dobutamine stress echocardiography, which may lead to coronary angiography or right heart catheterization. There is a paucity of data on the utility of RV hemodynamics during the perioperative period. Our objective was to determine if certain preoperative RV measurements distinguish which patients will experience post liver transplant RV failure. METHODS A retrospective study of liver transplant patients from 2015 through 2020 at the University of Cincinnati Medical Center was performed following IRB approval. Out of 389 patients, 13 had right heart failure based on ICD 10 code and discharge documentation. Preoperative echocardiographic data at baseline and peak stress were collected along with pre and postoperative RHC hemodynamics for comparison to age matched controls. Data was analyzed using two sample T tests in SPSS software. RESULTS Pre-operative RA pressure was higher in the RV failure group (12.5 vs. 6 p<0.001) and baseline PAPI was lower (1.97. vs. 3.54 p=0.02). Baseline TAPSE (2.05 vs. 2.52 p=0.03), stress TAPSE (2.75 vs. 3.22 p=0.02), and TAPSE augmentation (0.13 vs. 0.39 p=0.02) were lower in the RV failure group. Postoperatively, the RV failure group had higher RA pressure (10.01 vs. 7.46 p=0.04) and lower PAPI (1.44 vs. 3.34 p=0.004). There were no differences in mean PA and wedge pressure. The RV failure group had significantly more ventilator days (7.62 vs. 1.92 p<0.001), inotrope use (3.38 vs. 0 p<0.001), and pulmonary vasodilator use (1.93 vs. 0 p<0.001). Thirty day post-transplant mortality was 23% in the RV failure group and 0% in the control group. Data is represented in figure 1. DISCUSSION Cirrhosis causes hyperdynamic cardiac output leading to difficulty determining a pathologic level of dysfunction in these patients. Mean normal TAPSE and PAPI in the literature are 2.0cm and 2.75, respectively, but in our control group mean TAPSE was 2.52cm and PAPI was 3.54. This is likely explained by the high cardiac output state in cirrhosis. In the RV failure group, TAPSE and PAPI were within the normal range suggesting the need to identify a different baseline for patients with a hyperdynamic state due to cirrhosis. Mean PA pressure, commonly used to determine perioperative risk, did not have any discriminating ability between groups. Impaired RV reserve demonstrated by reduced TAPSE augmentation to stress may be a better predictor of RV failure in this patient population and identify patients that may be at risk for significant 30 day post-transplant mortality.