title: Evaluation of Arteriovenous Shunting in Patients With End-Stage Liver Disease: Potential Role of Early Right Heart Catheterization.
abstract: BACKGROUND
  In patients with end-stage liver disease (ESLD), the presence of hypoxemia suggests the presence of intrapulmonary oxygen shunting (IPS) and/or transatrial shunting. Early identification of each is imperative to avoid potentially fatal peritransplantation complications and appropriately prioritize patients for liver transplantation (LT). The aim of this work was to compare the sensitivity of transthoracic echocardiography (TTE) and right heart catheterization (RHC) with intracardiac echocardiography (ICE) for identifying the etiologies of resting hypoxemia in patients with ESLD being evaluated for LT.
  
  
  METHODS
  Records of 28 patients with ESLD and resting hypoxemia who underwent TTE with bubble study and RHC/ICE were reviewed. Patients with a patent foramen ovale (PFO) were compared with non-PFO patients to determine diagnostic accuracy of TTE with bubble study versus RHC/ICE.
  
  
  RESULTS
  TTE with bubble study diagnosed PFO, IPS, and pulmonary hypertension (PH), respectively, with sensitivities of 46%, 41%, and 25% and specificities of 46%, 45%, and 80% compared with RHC/ICE. Although IPS detected by RHC/ICE was more common in patients without a PFO (92%), 5 patients with a PFO (33%) also had IPS (P = .002). Isolated PH was detected exclusively in patients with a PFO (5/15; 33%).
  
  
  CONCLUSIONS
  TTE with bubble study is neither sensitive nor specific to exclude a PFO in patients with ESLD. RHC/ICE is a safe and accurate diagnostic/interventional modality in this group of patients and is useful to diagnose other comorbidities, such as IPS and PH, that may coexist and contribute to resting hypoxemia.
authors.affiliation: Division of Pediatric Cardiology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: M
authors.initials: M
authors.lastname: Nagiub
authors.affiliation: Section of Hepatology, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: R T
authors.initials: RT
authors.lastname: Stravitz
authors.affiliation: Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: D
authors.initials: D
authors.lastname: Grinnan
authors.affiliation: Division of Pediatric Cardiology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia. Electronic address: wmoskowitz@mcvh-vcu.edu.
authors.forename: W
authors.initials: W
authors.lastname: Moskowitz
mesh_terms: D006328:Cardiac Catheterization; D004452:Echocardiography; D058625:End Stage Liver Disease / Q000150:complications* / Q000601:surgery; D005260:Female; D054092:Foramen Ovale, Patent / Q000175:diagnosis; D006801:Humans; D006976:Hypertension, Pulmonary / Q000175:diagnosis; D000860:Hypoxia / Q000150:complications / Q000209:etiology*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011652:Pulmonary Circulation; D012189:Retrospective Studies