Hepatic Venous Flow Research Articles

A Case of Budd-Chiari Syndrome Associated with Erythrocytosis and Homozygous MTHFR C677T Mutation

An erythrocytosis describes an increased erythrocyte, subclassified into relative due to hemoconcentration or absolute by an increase in erythrocyte mass, defined as an increase in hemoglobin concentration and/or hematocrit in the peripheral blood above the sex-specific normal range. Budd-Chiari Syndrome (BCS) is related to an obstruction of the hepatic venous flow leading to occlusion of hepatic veins and their tributaries. Genetic and environmental factors can interact for risk determination of venous thromboembolism. The risk associated with SNP 677C>T and 1298A>C of the methylenetetrahydrofolate reductase (MTHFR), 1691G>A of the Factor V Leiden (FVL) and 20210G>A of the prothrombin (FII) genes were investigated in many studies involving thrombosis. This case report describes the clinical, hematological and biochemistry data about a 48-year-old woman diagnosed with PV and a BCS associated, also carrying 677C>T SNP in homozygosity. The patient started therapy with phlebotomy, hydroxyurea and oral anticoagulant. Currently, she presents a better clinical and laboratory condition with normalized values of hematological and platelet indices. This case report aims to contribute with evidence of related comorbidities and makes it possible to report that genetic factors are involved since the patient's mother had already been diagnosed with absolute erythrocytosis in 2016 at 78 years old. For this main result, we understand that it is clear that a family genetic study can reveal clinical modifying factors in these patients, as there are different clinical severities in the family. Furthermore, we believe in the need for a greater number of randomized clinical trials to add better evidence to complement an ideal therapeutic approach in these patients.

Correlation between Hepatic Vein Wave form Changes on Doppler Ultrasound and the Severity of Diseases in Cirrhotic Patients

Background: Cirrhosis is a common problem and is a leading cause of chronic liver disease. Early diagnosis with assessment of severity of diseases may help prevent the associated complications and patients’ sufferings. Now a days Hepatic venous Doppler can be a tool for diagnosis of cirrhosis and to assess correlation between waveform changes and severity of diseases. Objective: The purposes of this study was to determine the significance of hepatic vein waveform changes on doppler ultrasound in cirrhotic patients and to correlate with liver dysfunction. Materials and methods: This study was carried out in the department of Radiology and Imaging of Enam Medical College and Hospital during January 2017 to May 2018. Doppler waveforms were obtained from right hepatic vein in all the cases and classified as triphasic, biphasic and monophasic. Waveform comparisons were made among patients with differing grades of cirrhosis. Child- Pugh class was used to assess severity of cirrhosis. Doppler sonography was done in 80 patients suspecting of having liver cirrhosis. Data on clinical findings, B mode sonographic findings and hepatic vein doppler ultrasound findings were collected and documented in structured forms. Analysis was done using SPSS - 20. Results: Total of 80 patients who met the inclusion criteria are included in the study with mean age of 45.37±7.64 (range 25-75) years. Among these 57 (71%) were males while 23(29%) were females. On the basis of hepatic function 25 (31%) patients presented in Child-Pugh Class A, 31(39%) with Class B and 24(30%) patients had Class C. Hepatic venous waveform was triphasic in 22 (27.5%), biphasic in 28(35%), and monophasic in 30 (37.5%) cases. Our study revealed 88% (21) of Child- Pugh Class C, 23% (7) of Class B and 8% (2) of class A patients had monophasic HV waveform. The hepatic venous waveform progressively changed from triphasic to biphasic to monophasic with advancing grade of cirrhosis. The relationship of these waveforms change had significant relation with hepatic dysfunction (p < 0.022). Conclusion: Hepatic vein wave form changes reflects the change in hepatic circulation associated with progression of liver cirrhosis. It can be used as a new parameter in the assessment of severity of liver cirrhosis. Thus, alteration in hepatic venous blood flow pattern on doppler ultrasound can be a useful noninvasive tool for evaluating diseases severity in patients with cirrhosis. J MEDICINE 2021; 22: 100-106

Extracardiac conduit adequacy along the respiratory cycle in adolescent Fontan patients.

OBJECTIVESAdequacy of 16–20mm extracardiac conduits for adolescent Fontan patients remains unknown. This study aims to evaluate conduit adequacy using the inferior vena cava (IVC)–conduit velocity mismatch factor along the respiratory cycle.METHODSReal-time 2D flow MRI was prospectively acquired in 50 extracardiac (16–20mm conduits) Fontan patients (mean age 16.9 ± 4.5 years) at the subhepatic IVC, conduit and superior vena cava. Hepatic venous flow was determined by subtracting IVC flow from conduit flow. The cross-sectional area (CSA) was reported for each vessel. Mean flow and velocity was calculated during the average respiratory cycle, inspiration and expiration. The IVC–conduit velocity mismatch factor was determined as follows: Vconduit/VIVC, where V is the mean velocity.RESULTSMedian conduit CSA and IVC CSA were 221 mm2 (Q1–Q3 201–255) and 244 mm2 (Q1–Q3 203–265), respectively. From the IVC towards the conduit, flow rates increased significantly due to the entry of hepatic venous flow (IVC 1.9, Q1–Q3 1.5–2.2) versus conduit (3.3, Q1–Q3 2.5–4.0 l/min, P < 0.001). Consequently, mean velocity significantly increased (IVC 12 (Q1–Q3 11–14 cm/s) versus conduit 25 (Q1–Q3 17–31 cm/s), P < 0.001), resulting in a median IVC–conduit velocity mismatch of 1.8 (Q1–Q3 1.5–2.4), further augmenting during inspiration (median 2.3, Q1–Q3 1.8–3.0). IVC–conduit mismatch was inversely related to measured conduit size and positively correlated with conduit flow. The normalized IVC–conduit velocity mismatch factor during expiration and the entire respiratory cycle correlated with peak VO2 (r = –0.37, P = 0.014 and r = –0.31, P = 0.04, respectively).CONCLUSIONSImportant blood flow accelerations are observed from the IVC towards the conduit in adolescent Fontan patients, which is related to peak VO2. This study, therefore, raises concerns that implanted 16–20mm conduits have become undersized for older Fontan patients and future studies should clarify its effect on long-term outcome.

Should we use diastolic function parameters to determine preload responsiveness in cardiac surgery? A pilot study

BackgroundLeft ventricular (LV) diastolic function (DF) may play an important role in predicting fluid responsiveness. However, few studies assessed the role of diastolic function in predicting fluid responsiveness. The aim of this pilot study was to assess whether parameters of right and left diastolic function assessed with transesophageal echocardiography, including the mitral E/e′ ratio, is associated with fluid responsiveness among patients undergoing elective bypass graft surgery. We also sought to compare other methods of fluid responsiveness assessment, including echocardiographic and hemodynamic parameters, pulse pressure variation, and stroke volume variation (SVV) (arterial pulse contour analysis, Flotrac/Vigileo system).ResultsWe prospectively studied seventy patients undergoing coronary artery bypass grafting (CABG) monitored with a radial arterial catheter, transesophageal echocardiography (TEE), and a pulmonary artery catheter (for cardiac output measurements), before and after the administration of 500 mL of crystalloid over 10 min after the anesthetic induction. Thirteen patients were excluded (total of 57 patients). Fluid responsiveness was defined as an increase in cardiac index of ≥ 15%. There were 21 responders (36.8%) and 36 non-responders (63.2%). No difference in baseline pulsed wave Doppler echocardiographic measurements of any components of the mitral, tricuspid, and pulmonary and hepatic venous flows were found between responders and non-responders. There was no difference in MV tissue Doppler measurements between responders and non-responders, including E/e′ ratio (8.7 ± 4.1 vs. 8.5 ± 2.8 in responders vs. non-responders, P = 0.85). SVV was the only independent variable to predict an increase in cardiac index by multivariate analysis (P = 0.0208, OR = 1.196, 95% CI (1.028-1.393)).ConclusionsIn this pilot study, we found that no parameters of right and left ventricular diastolic function were associated with fluid responsiveness in patients undergoing CABG. SVV was the most useful parameter to predict fluid responsiveness.Trial registrationClinicalTrials.gov, NCT 02714244. Registered 21 March 2016—retrospectively registered.

THE ASSOCIATION BETWEEN PREOPERATIVE AND POSTOPERATIVE HEPATIC VENOUS FLOW AND THE OUTCOME AFTER CARDIAC SURGERY

Introduction The hepatic venous flow reflects the pressure changes of the right ventricle. (1) Therefore, it starts to appear as a part of the echocardiographic examinations. Moreover, the back-and-forth link between the cardiovascular state and the liver is well-known for several years. (2,3) Our objective was to evaluate the association between preoperative and postoperative hepatic venous flow and the outcome of patients who underwent cardiac surgery. Methods Our prospective, observational study included 30 patients who underwent cardiac surgery between 2021 January and June at our Heart and Vascular Centre. Beside the routine echocardiographic examination, we also measured the venous blood flow in the common hepatic vein before the influx into the Inferior Vena Cava with Doppler ultrasound before and after the surgical procedure. We recorded the standard four waves’ (V, D, S, A) maximal speed and velocity time integral (VTI). In our database we recorded the patients’ demographic data, preoperative and postoperative hemodynamic and hepatobiliar markers and the EuroSCORE. We collected the length of stay (LOS), the intensive care unit stay, the vasopressor and inotrope need, and the occurrence of acute kidney injury (AKI). Our primary outcome was AKI, it was defined by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines, which is one of the first signs of circulation problems. We used the SPSS 22 program to analyse our data, with descriptive parameters and Cox-regression analyses. Results Median age was 67.9 (IQR 25-75: 60.6-73.6), none of them had any liver or renal disease in their medical history. Most common surgical procedure was AVR (atrial valve repair) (40%). During the first postoperative week 6 patients developed AKI. Between the AKI and non-AKI subgroups with Inverse Probability Weighting we found a significant difference at the postoperative A and D waves’ VTI, (p=0,031 and 0,022) and the preoperative retrograde/anterograde waves’ VTI ratio after adjustment for age, Euroscore, diabetes and GFR. (p=0,001). With paired-samples T test the V waves’ VTI's difference was significant between the preoperative and postoperative measurement. Discussion The increment in the hepatic venous retrograde waves, which are related to hepatic stasis, can predict worse outcomes among cardiac patients. Therefore, we might include this potentially useful tool in routine echocardiographic examinations and monitoring through the whole hospital stay.

Non-uniform mixing of hepatic venous flow and inferior vena cava flow in the Fontan conduit.

Fontan patients require a balanced hepatic blood flow distribution (HFD) to prevent pulmonary arteriovenous malformations. Currently, HFD is quantified by tracking Fontan conduit flow, assuming hepatic venous (HV) flow to be uniformly distributed within the Fontan conduit. However, this assumption may be unvalid leading to inaccuracies in HFD quantification with potential clinical impact. The aim of this study was to (i) assess the mixing of HV flow and inferior vena caval (IVC) flow within the Fontan conduit and (ii) quantify HFD by directly tracking HV flow and quantitatively comparing results with the conventional approach. Patient-specific, time-resolved computational fluid dynamic models of 15 total cavopulmonary connections were generated, including the HV and subhepatic IVC. Mixing of HV and IVC flow, on a scale between 0 (no mixing) and 1 (perfect mixing), was assessed at the caudal and cranial Fontan conduit. HFD was quantified by tracking particles from the caudal (HFDcaudal conduit) and cranial (HFDcranial conduit) conduit and from the hepatic veins (HFDHV). HV flow was non-uniformly distributed at both the caudal (mean mixing 0.66 ± 0.13) and cranial (mean 0.79 ± 0.11) level within the Fontan conduit. On a cohort level, differences in HFD between methods were significant but small; HFDHV (51.0 ± 20.6%) versus HFDcaudal conduit (48.2 ± 21.9%, p = 0.033) or HFDcranial conduit (48.0 ± 21.9%, p = 0.044). However, individual absolute differences of 8.2–14.9% in HFD were observed in 4/15 patients. HV flow is non-uniformly distributed within the Fontan conduit. Substantial individual inaccuracies in HFD quantification were observed in a subset of patients with potential clinical impact.

Clinical and Diagnostic Profile and Management of Inferior Vena Cava Obstruction- A Descriptive Study at a Tertiary Care Centre, Hyderabad

Introduction: Obstruction to hepatic venous outflow is a rare disease with a potentially fatal outcome, if not recognised and managed promptly. The level of obstruction can vary, anywhere from the small hepatic venules to the entry point of the Inferior Vena Cava (IVC) into the right atrium. The original patients that Budd-Chiari described had acute hepatic vein thrombosis but this syndrome now encompasses various hepatic venous outflow blocks, of which a membrane in the IVC is the most common anatomical form of obstruction. Pure IVC obstruction is commonly seen among Asians. Aim: To study the clinical and diagnostic profile of patients presenting with IVC obstruction and to evaluate the treatment efficacy and safety of percutaneous transluminal angioplasty. Materials and Methods: For this prospective, descriptive study, from November 2015 to August 2019, a total of 21 patients were admitted with obstruction of hepatic venous flow. Most of the patients were young adults. Clinical features, aetiologies and coagulation profiles were studied. Ascites, pain abdomen and pedal oedema were common presentations. Diagnosis was established by clinical examination and was confirmed by ultrasound-doppler study, computed tomography and conventional angiography. Statistical analysis was done by using statistical package for social sciences IBM SPSS statistics for Windows, version 20.0. The data were expressed as percentages of study population while, continuous data were expressed as mean±standard deviation. Results: The mean age of the population was 24.7±2.9 years, with a female preponderance. (male: female=1:2). IVC angiography was done in 15 patients. Seven of the 15 patients had diffuse narrowing of IVC. Eight patients had focal or segmental narrowing of IVC, among them seven patients underwent Percutaneous Transluminal Angioplasty (PTA) with stenting. The venous access was obtained from femoral vein. The stenoses were crossed with either guide wire or Brocken brough needle with Mullins sheath. Three patients did not need predilatation. In four patients, obstructed IVC was dilated with Inoue balloon and then self-expanding stents were placed. Success was achieved in all cases, with significant drop in the pressure gradients from 20±5 mmHg before procedure to 3±2 mmHg immediately after the procedure. After PTA, all seven patients had either total relief or decrease of symptoms and clinical signs of hepatic venous obstruction. No major complications were observed and no repeat interventions were required. The mean postprocedural follow-up was six months that showed good outcomes with good stent patency. Conclusion: Chronic obstruction of IVC presents with abdominal pain, progressive ascites and portal hypertension in young adults, with mild abnormality of liver function tests. The IVC obstruction can be due to an obstructive membrane or segmental stenosis or diffuse narrowing of IVC. PTA with stenting can be done safely and it effectively relieves the symptoms and venous congestion and can be considered as the first line decompressive procedure in patients with IVC stenosis.

Alteration of contrast enhanced ultrasound (CEUS) of hepatocellular carcinoma in patients with cirrhosis and transjugular intrahepatic portosystemic shunt (TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS) can treat portal hypertensive complications and modifies hepatic hemodynamics. Modification of liver perfusion can alter contrast enhancement dynamics of liver nodules. This study investigated the diagnostic performance of contrast-enhanced ultrasound (CEUS) to diagnose hepatocellular carcinoma (HCC) in cirrhosis with TIPS. In this prospective monocentric observational study, CEUS was used to characterize focal liver lesions in patients at risk for HCC with and without TIPS. Times of arterial phase hyperenhancement (APHE) und washout were quantified. Perfusion-index (PI) and resistance-index (RI) of hepatic artery and portal venous flow parameters were measured via doppler ultrasonography. Diagnostic gold standard was MRI/CT or histology. This study included 49 liver lesions [23 TIPS (11 HCC), 26 no TIPS (15 HCC)]. 26 were diagnosed as HCC by gold standard. Sensitivity and specificity of CEUS to diagnose HCC with and without TIPS were 93.3% and 100% vs. 90.9% and 93.3%, respectively. APHE appeared significantly earlier in patients with TIPS compared to patients without TIPS. TIPS significantly accentuates APHE of HCC in CEUS. CEUS has good diagnostic performance for diagnosis of HCC in patients with TIPS.

Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study.

BackgroundFluid overload is deleterious in critically ill patients. It can lead to venous congestion, thereby increasing venous pressure, theoretically increasing the backpressure, and thereby reducing renal blood flow. Venous congestion thus can be an important contributor to acute kidney injury (AKI), with no validated tools to objectively identify venous congestion bedside.Materials and methodsPatients above 18 years admitted in ICU with a provisional diagnosis of cardiorenal syndrome were included in the study. Those with inadequate window, inferior vena cava (IVC) thrombus, and known case of cirrhosis with portal hypertension were excluded from the study. Patients underwent ultrasound examination with serial determination till AKI resolved or patient is initiated on dialysis. Venous excess ultrasound score (VEXUS) comprising inferior vena cava, hepatic vein waveform, and portal vein pulsatility was assessed.ResultsThirty patients were enrolled for the study. The mean age was 59.53 ± 16.47 with 21 (70%) males. Mean sequential organ failure assessment (SOFA) score was 5.03 ± 1.97. Fourteen patients (46.7%) were in AKI stage 1, while eight patients (26.7%) were in AKI stage 2 and stage 3 each. Twenty patients (66.7%) had VEXUS grade III. Resolution of AKI injury showed significant correlation with improvement in VEXUS grade (p value 0.003). Similarly, there was significant association between changes in VEXUS grade and fluid balance (p value 0.006). There was no correlation between central venous pressure (CVP), left ventricular function, and right ventricular function with change in VEXUS grade.ConclusionThe study shows that a combined grading of IVC, hepatic vein, and portal vein might reliably demonstrate venous congestion and aid in the clinical decision to perform fluid removal.How to cite this articleBhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020;24(9):783–789.

Doppler Interrogation of the Femoral Vein in the Critically Ill Patient: The Fastest Potential Acoustic Window to Diagnose Right Ventricular Dysfunction?

To report the use of common femoral vein Doppler interrogation as a simple technique to diagnose right ventricular dysfunction. Case report. Cardiac surgical ICU. Postoperative cardiac surgical patients. Common femoral pulsed-wave and color Doppler examination associated with hepatic, portal, and renal venous Doppler measurement were obtained in both patients and before and after treatment in patient number 1. In addition, right ventricular pressure waveform examination was obtained in patient number 2. The technique to obtain common femoral venous Doppler is described. Two cases of patients presenting with right ventricular dysfunction and fluid overload with portal and renal venous congestion in the perioperative period undergoing complex multivalvular cardiac surgery are presented. Hemodynamic waveform monitoring was performed alongside echocardiographic, hepatic, and renal venous flow Doppler assessment, and spectral Doppler profiles of the common femoral veins were examined. Those findings were useful in confirming our diagnosis and guiding our response to treatment. An algorithm was developed and tested on two additional hemodynamically unstable patients. Doppler examination of the common femoral vein is a simple, fast, and noninvasive technique that could be useful to rule in the presence of right ventricular dysfunction with venous congestion and help guide the management of such patients.

A computational model-based study on the exchangeability of hepatic venous pressure gradients measured in multiple hepatic veins

Hepatic venous pressure gradient (HVPG) is a hemodynamic index widely used for evaluating the severity of portal hypertension. Theoretically, HVPG can be measured in any of the three major (i.e., right, middle and left) hepatic veins (HVs); however, it remains unclear whether HVPGs measured in different HVs are exchangeable, and if not, what factors cause inter-HV HVPG differences? In consideration of the potential limitations of invasive in vivo measurements, we employed a computational model implemented in conjunction with stochastic parameter sampling to simulate and compare HVPG measurements in multiple HVs under various sinusoidal portal hypertensive conditions. Results demonstrated that HVPGs measured in the right and middle HVs were basically exchangeable, whereas those in the left HV were relatively lower due primarily to the smaller proportion of hepatic venous flow through the left HV compared with that through the right or middle HV. Moreover, it was found that hepatic vein-to-vein shunts (HVVS) led to a marked augmentation of inter-HV HVPG differences and significant underestimation of portal pressure gradient with HVPG. These findings suggest that understanding the distribution of hepatic venous flow and status of HVVS is essential for selecting a proper HV for implementing HVPG measurement in clinical practice.

Doppler characteristics of hepatic venous hemodynamics in adult healthy camels (Camelus dromedarius)

Abstract The present study was designed to describe the Doppler measurements of hepatic venous blood flow in camels (Camelus dromedarius). A total number of 9 adult healthy camels underwent hepatic Doppler examinations on the right side between the 11th and 9th intercostal spaces. The splenic and cranial mesenteric veins showed turbulent blood flows at their fusion to form the main portal trunk. At porta hepatis, the main portal vein exhibited turbulent blood flows and the mean velocities ranged from 21 to 28 cm/sec. In contrast, the intrahepatic branches of portal veins revealed smooth laminar spectral patterns with low blood velocities ranged from 12 to 22 cm/sec. In addition, hepatic veins and caudal vena cava have laminar blood flows. In conclusion, as a non-invasive clinical tool, Doppler ultrasonography is a simple and easy applicable method for assessment of hepatic hemodynamics in camels (Camelus dromedaries). The present findings have the potential to serve as references for evaluating the health status of the liver from camels. Therefore; a further research study, including comparative evaluation of Doppler findings in camels with various hepatic diseases, may be required.

Preliminary Experience Using Diastolic Right Ventricular Pressure Gradient Monitoring in Cardiac Surgery

Right ventricular (RV) dysfunction in cardiac surgery is associated with increased mortality and morbidity and difficult separation from cardiopulmonary bypass (DSB). The primary objective of the present study was to describe the prevalence and characteristics of patients with abnormal RV diastolic pressure gradient (PG). The secondary objective was to explore the association among abnormal diastolic PG and DSB, postoperative complications, high central venous pressure (CVP), and high RV end-diastolic pressure (RVEDP). Retrospective and prospective validation study. Tertiary care cardiac institute. Cardiac surgical patients (n=374) from a retrospective analysis (n=259) and a prospective validation group (n=115). RV pressure waveforms were obtained using a pulmonary artery catheter with a pacing port opened at 19 cm distal to the tip of the catheter. Abnormal RV diastolic PG was defined as >4 mmHg. Both elevated RVEDP and high CVP were defined as >16 mmHg. From the retrospective and validation cohorts, 42.5% and 48% of the patients had abnormal RV diastolic PG before cardiac surgery, respectively. Abnormal RV diastolic PG before cardiac surgery was associated with higher EuroSCORE II (odds ratio 2.29 [1.10-4.80] v 1.62 [1.10-3.04]; p = 0.041), abnormal hepatic venous flow (45% v 29%; p = 0.038), higher body mass index (28.9 [25.5-32.5] v 27.0 [24.9-30.5]; p = 0.022), pulmonary hypertension (48% v 37%; p = 0.005), and more frequent DSB (32% v 19%; p = 0.023). However, RV diastolic PG was not an independent predictor of DSB, whereas RVEDP (odds ratio 1.67 [1.09-2.55]; p = 0.018) was independently associated with DSB. In addition, RV pressure monitoring indices were superior to CVP in predicting DSB. Abnormal RV diastolic PG is common before cardiac surgery and is associated with a higher proportion of known preoperative risk factors. However, an abnormal RV diastolic PG gradient is not an independent predictor of DSB in contrast to RVEDP.

Characterization of Doppler spectrum of hepatic veins and correlation with structural and functional variables of the right ventricle in healthy dogs.

BackgroundSpectral Doppler assessment of hepatic veins may provide information on heart function.Hypothesis/ObjectivesTo assess the normal pattern of hepatic venous flow using spectral Doppler ultrasound examination; to correlate this information with structural and functional variables of the right ventricle (RV), and to analyze the impact of age, sex, body weight quartiles, heart rate, cardiac rhythm, and systolic arterial pressure on the results in healthy dogs.AnimalsSixty‐five healthy dogs.MethodsCross‐sectional observational study. The direction and maximum velocity of each of the 4 possible components of venous flow were determined from pulsed‐wave Doppler examination of the hepatic veins. In addition, structural and functional parameters (TAPSE, longitudinal strain, FAC%, S′, Et/At, and E′t/ A′t) of the RV were evaluated.ResultsThe same phase patterns for different waves were seen in all animals: A and V were retrograde waves, and S and D were anterograde waves. The velocity of the spectral waves increased with body weight (P < .05) and could be correlated with functional indices of the RV. A significant difference was found when comparing morphometric indices with body weight quartiles (P < .05). In addition, intra‐and inter‐observer assessments showed low variability. The mean duration of the examinations was 5.2 minutes.Conclusions and Clinical ImportanceHepatic spectral Doppler findings can be correlated with systolic and diastolic indices of the RV and vary with body weight.

Hepatic flow is an intraoperative predictor of early allograft dysfunction in whole-graft deceased donor liver transplantation: An observational cohort study.

BACKGROUNDEarly allograft dysfunction (EAD) after liver transplantation (LT) is an important cause of morbidity and mortality. To ensure adequate graft function, a critical hepatocellular mass is required in addition to an appropriate blood supply. We hypothesized that intraoperative measurement of portal venous and hepatic arterial flow may serve as a predictor in the diagnosis of EAD.AIMTo study whether hepatic flow is an independent predictor of EAD following LT.METHODSThis is an observational cohort study in a single institution. Hepatic arterial blood flow and portal venous blood flow were measured intraoperatively by transit flow. EAD was defined using the Olthoff criteria. Univariate and multivariate analyses were used to determine the intraoperative predictors of EAD. Survival analysis and prognostic factor analysis were performed using the Kaplan-Meier and Cox regression models.RESULTSA total of 195 liver transplant procedures were performed between January 2008 and December 2014 in 188 patients. A total of 54 (27.7%) patients developed EAD. The median follow-up was 39 mo. Portal venous flow, hepatic arterial flow (HAF) and total hepatic arterial flow were associated with EAD in both the univariate and multivariate analyses. HAF is an independent prognostic factor for 30-d patient mortality.CONCLUSIONIntraoperative measurement of blood flow after reperfusion appears to be a predictor of EAD; Moreover, HAF should be considered a predictor of 30-d patient mortality.

One-year survival impact of early right ventricular diastolic dysfunction after lung transplantation

Introduction Right ventricular (RV) diastolic dysfunction is known to be associated with increased mortality in heart failure or cardiac surgical patients (pts). However, after lung transplantation (LTx), the impact of early RV diastolic dysfunction on 1-year survival, in a population without pulmonary hypertension, is not well documented. Methods We routinely perform a comprehensive transoesophageal echocardiography (TOE) after ICU admission of LTx patients (pts) to check the pulmonary veins’ patency. After exclusion of pts transplanted for pulmonary hypertension and of pts under ECMO, we retrospectively reviewed the diastolic RV parameters acquired during this TOE. At that time, all pts were mechanically ventilated. RV diastolic function was explored by tricuspid peak early and late velocities (E and A waves) (pulsed-wave Doppler (PW) through the tricuspid valve), early diastolic peak velocity (Ea) of the lateral tricuspid annulus (PW-TDI), hepatic venous flow (HVF) pattern (PW Doppler), and characterized as normal or abnormal according to the algorithm validated by Shi et al. One-year survival status was recorded. Continuous variables are presented as median [interquartile range] and analysed with Mann-Whitney U test. Dichotomous variables are presented as numbers (%) and analysed with Chi-Squared test. Results From May 2008 to March 2018, RV diastolic data were available in 69 pts. Indications for LTx were COPD in 51 pts (73.9%), fibrosis in 12 (17.4%), bronchiectasis in 1 pt (1.5%) and other indications in 5 (7.2%). RV diastolic function was categorized as abnormal in 47pts. One-year survival rate was 72.3% (34/47) in the group with early RV diastolic dysfunction and 95.4% (1/22) in the group with normal RV diastolic function (P = 0.027). Discussion Based on these retrospective TOE data in this single-center experience, occurrence of early RV diastolic dysfunction after LTx seems to be associated with impaired 1-year survival. Further prospective data are needed to confirm these preliminary observations.

Comparative study on selective hepatic vascular exclsion and total hepatic vascular exclusion for hepatic trauma with major hepatic vein injury

Objective To compare the effect of selective hepatic vascular exclsion (SHVE) and total hepatic vascular exclusion (THVE) in the treatment of hepatic trauma with major hepatic vein injury. Methods A retrospective case control study was conducted to analyze the clinical data of 42 patients with hepatic trauma accompanied by hepatic vein injury admitted to multiple centers from April 2000 to December 2017. There were 30 males and 12 females, aged 14-65 years [(40.2±18.8)years]. Blood flow exclusion was operated through HVE in 22 patients (SHVE group) and through THVE in 20 patients (THVE group). SHVE group included 22 patients (16 males and six females), aged (40.1±19.4)years. There were 10 patients with grade IV and 12 with grade V according to American Association of Traumatic Surgery (AAST) classification of liver injury. In terms of the hepatic vein injury, there were 13 patients with type I, eight with type III, and one with type IV. THVE group included 20 patients (14 males and six females), aged (39.9±18.2)years. There were nine patients with grade IV and 11 with grade V according to AAST classification of liver injury. In terms of the hepatic vein injury, there were 11 patients with type I, seven with type III, and two with type IV. The operation approach, operation time, hepatic warm ischemia time, blocking time of hepatic vein blood flow, amount of abdominal hemorrhage, intraoperative blood loss, postoperative blood loss, intraoperative infusion, total blood transfusion, length of ICU stay after operation, length of hospital stay after operation, function of liver and kidney after operation, incidence of complications and mortality were compared between the two groups. Results There were no significant differences in the amount of abdominal hemorrhage, intraoperative blood loss, postoperative blood loss, perioperative blood transfusion, surgical procedure, and postoperative liver and kidney function between the two groups (P>0.05). The THVE group had significantly longer operation time, hepatic warm ischemia time, hepatic venous blood flow blocking time, postoperative ICU time and postoperative hospital stay than the SHVE group (P<0.05). The amount of infusion in the SHVE group was less than that in the THVE group (P<0.05). The incidence of complications in SHVE group was 27% (6/22), lower than that in THVE group [60% (12/20)] (P<0.05). The mortality of SHVE group was 14% (3/22), lower than that of THVE group [45% (9/20)](P<0.05). Conclusions SHVE and THVE can effectively control bleeding in the treatment of hepatic trauma with main hepatic vein injury. SHVE has more advantages over THVE in shortening operation time, warm ischemia time of liver, blocking time of hepatic vein blood flow, ICU stay after operation, hospital stay after operation and reducing intraoperative infusion volume, and can reduce the incidence of complications and mortality. Key words: Digestive system diseases; Liver; Hepatic veins; Hepatic vascular exclusion

Predictive Value of Intraoperative Indocyanine Green Clearance Measurement on Postoperative Liver Function After Anatomic Major Liver Resection

BackgroundThe aim of this study was to evaluate the predictive value of measuring indocyanine green (ICG) clearance during intraoperative partial occlusion of liver lobes to be resected on postoperative liver function following major anatomic liver resection. MethodsWe prospectively included 46 patients, and 35 patients ultimately underwent anatomic major liver resection. ICG clearance was measured preoperatively and intraoperatively. Intraoperative ICG clearance was measured immediately after selective occlusion of hepatic arterial, portal, and hepatic venous blood flow to the liver lobes to be resected. The albumin-bilirubin (ALBI) grade, albumin-indocyanine green evaluation (ALICE) grade, platelet count, remnant liver volume per kilogram of weight (RLV/kg), and future liver remnant plasma clearance rate of ICG (ICGK-FLR) were measured preoperatively. ResultsAn intraoperative ICG retention at 15 min (I-R15) greater than 13.8% indicates transient posthepatectomy liver failure (PHLF) and Clavien-Dindo > grade I complications. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) for predicting PHLF and Clavien-Dindo > grade I complications was 0.797 and 0.734, respectively (p = 0.001 and 0.014). Furthermore, an I-R15 greater than 22.7% indicates mid-term PHLF, and the AUC was 0.911 (p < 0.0001). The I-R15 is a better predictor of PHLF than the ALBI grade, ALICE grade, platelet count, RLV/kg, and ICGK-FLR. ConclusionsIntraoperative ICG clearance measurements during partial occlusion of blood flow accurately predict postoperative liver function and could be new criteria for determining the feasibility and safety of anatomic major liver resection.

Somatostatin as Inflow Modulator in Liver-transplant Recipients With Severe Portal Hypertension: A Randomized Trial.

To investigate the safety and efficacy of somatostatin as liver inflow modulator in patients with end-stage liver disease (ESLD) and clinically significant portal hypertension (CSPH) undergoing liver transplantation (LT) (ClinicalTrials.gov number,01290172). In LT, portal hyperperfusion can severely impair graft function and survival, mainly in cases of partial LT. Thirty-three patients undergoing LT for ESLD and CSPH were randomized double-blindly to receive somatostatin or placebo (2:1). The study drug was administered intraoperatively as 5-mL bolus (somatostatin: 500 μg), followed by a 2.5 mL/h infusion (somatostatin: 250 μg/h) for 5 days. Hepatic and systemic hemodynamics were measured, along with liver function tests and clinical outcomes. The ischemia-reperfusion injury (IRI) was analyzed through histological and protein expression analysis. Twenty-nine patients (18 receiving somatostatin, 11 placebo) were included in the final analysis. Ten patients responded to somatostatin bolus, with a significant decrease in hepatic venous portal gradient (HVPG) and portal flow of -28.3% and -29.1%, respectively. At graft reperfusion, HVPG was lower in patients receiving somatostatin (-81.7% vs -58.8%; P = 0.0084), whereas no difference was observed in the portal flow (P = 0.4185). Somatostatin infusion counteracted the decrease in arterial flow (-10% vs -45%; P = 0.0431). There was no difference between the groups in the severity of IRI, incidence of adverse events, long-term complications, graft, and patient survival. Somatostatin infusion during LT in patients with CSPH is safe, reduces the HVPG, and preserves the arterial inflow to the graft. This study establishes the efficacy of somatostatin as a liver inflow modulator.

Fontan Revision: Presurgical Planning Using Four-Dimensional (4D) Flow and Three-Dimensional (3D) Printing.

Pulmonary arteriovenous malformations (AVMs) can be a complication of certain postoperative Fontan patients whose hepatic venous blood return is not distributed evenly to both lungs. A ten-year-old female, who had previously undergone staged single ventricle palliation for complex congenital heart disease, underwent a Fontan revision due to significant left-sided pulmonary AVMs and increasing arterial oxygen desaturation. The combination of four-dimensional flow cardiac magnetic resonance imaging and three-dimensional printing enabled presurgical planning for a Fontan takedown and diversion of hepatic venous flow to the azygous vein that resulted in significant clinical improvement.