title: Intrapulmonary vascular dilatations are common in portopulmonary hypertension and may be associated with decreased survival.
abstract: Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are pulmonary vascular complications of portal hypertension with divergent clinicopathologic features and management. The presence of intrapulmonary vascular dilatations (IPVDs), detected by agitated saline contrast-enhanced transthoracic echocardiography (cTTE), is an essential feature of HPS but is not typically characteristic of POPH. Although IPVDs have been reported rarely in POPH, the prevalence and significance of this finding have not been systematically studied. We conducted a retrospective chart review of 80 consecutive patients diagnosed with POPH from January 1, 2002 to June 30, 2014 with documentation of cTTE findings, pulmonary hemodynamics, oxygenation, and survival. A total of 34 of the 80 patients (42%) underwent cTTE during initial diagnosis of POPH. IPVDs were detected in 20/34 patients (59%); intracardiac shunting was detected in 9/34 patients (26%; 4 also had IPVDs); and 9 patients (26%) had negative cTTE with no evidence of IPVD or intracardiac shunting. Patients with IPVD had decreased survival as compared to those without IPVD (P = 0.003), a trend that persisted after exclusion of liver transplant recipients (P =  0.07). The IPVD group had a trend toward higher Model for End-Stage Liver Disease score with and without incorporating sodium (MELD or MELD-Na; P = 0.05 for both). The right ventricular index of myocardial performance (RIMP) was lower in the IPVD group (median, 0.4 versus 0.6; P = 0.006). Patients with moderate or large IPVDs (n = 6) had worse oxygenation parameters (partial pressure of arterial oxygen, diffusing capacity of the lung for carbon monoxide, and alveolar-arterial oxygen gradient) as compared to the rest of the cohort. Unexpectedly, IPVDs were frequently documented in POPH and associated with decreased survival. To further understand this observation, we recommend screening for IVPD in all patients with POPH.
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine.
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Fussner
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine.
authors.forename: Vivek N
authors.initials: VN
authors.lastname: Iyer
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Cartin-Ceba
authors.affiliation: Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Grace
authors.initials: G
authors.lastname: Lin
authors.affiliation: Divisions of Gastroenterology and Hepatology, Mayo Clinic Transplant Center, Rochester, Minnesota.
authors.forename: Kymberly D
authors.initials: KD
authors.lastname: Watt
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine.|Divisions of Gastroenterology and Hepatology, Mayo Clinic Transplant Center, Rochester, Minnesota.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Krowka
mesh_terms: D004108:Dilatation, Pathologic; D004452:Echocardiography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D020065:Hepatopulmonary Syndrome / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality*; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications / Q000175:diagnosis; D008168:Lung / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D008910:Minnesota / Q000453:epidemiology; D011379:Prognosis; D011651:Pulmonary Artery / Q000000981:diagnostic imaging*; D011652:Pulmonary Circulation; D011667:Pulmonary Veins / Q000000981:diagnostic imaging*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends