title: Predictive Value of Dobutamine Stress Perfusion Echocardiography in Contemporary End-Stage Liver Disease.
abstract: The assessment of cardiac risk in contemporary liver transplantation (LT) has required more sensitive testing for the detection of occult coronary artery disease as well as microvascular and functional cardiac abnormalities. Because dobutamine stress perfusion echocardiography provides an assessment of both regional systolic and diastolic function as well as microvascular perfusion (MVP), we sought to examine its incremental value in this setting.
  
  
  
  We evaluated the predictive value of dobutamine stress perfusion echocardiography in 296 adult patients with end-stage liver disease and preserved systolic function who underwent LT between 2008 and 2014. The primary outcome was cardiovascular death, nonfatal myocardial infarction, and/or sustained ventricular arrhythmias following LT. The main causes of liver failure were hepatitis C (25%) and nonalcoholic fatty liver disease (13%). Abnormal MVP during stress was observed in 18 patients (6%), whereas diastolic dysfunction was present in 109 patients (94 grade 1, 15 grade 2). Half of the patients (7 of 14) referred for angiography with abnormal MVP had significant epicardial disease by angiography, and these patients were revascularized prior to LT. Despite these interventions, the primary outcome still occurred in 9 patients (3%). Patients with abnormal MVP during dobutamine stress perfusion echocardiography had a 7-fold higher risk of a cardiovascular event following LT. Cox proportional hazards modeling examining clinical variables, left ventricular ejection fraction, diastolic function, and stress-induced wall motion abnormalities or MVP defects demonstrated that abnormal MVP was the only independent predictor of the primary outcome (P=0.004; hazard ratio 7.7).
  
  
  
  Stress MVP assessments are highly predictive of cardiovascular outcome in current LT candidates.
authors.affiliation: University of Nebraska Medical Center, Omaha, NE.
authors.forename: Bipul
authors.initials: B
authors.lastname: Baibhav
authors.affiliation: University of Nebraska Medical Center, Omaha, NE.
authors.forename: Chetaj A
authors.initials: CA
authors.lastname: Mahabir
authors.affiliation: University of Nebraska Medical Center, Omaha, NE.
authors.forename: Feng
authors.initials: F
authors.lastname: Xie
authors.affiliation: University of Nebraska Medical Center, Omaha, NE.
authors.forename: Valerie K
authors.initials: VK
authors.lastname: Shostrom
authors.affiliation: University of Nebraska Medical Center, Omaha, NE.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: McCashland
authors.affiliation: University of Nebraska Medical Center, Omaha, NE trporter@unmc.edu.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Porter
mesh_terms: D002316:Cardiotonic Agents / Q000494:pharmacology; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis*; D004280:Dobutamine / Q000494:pharmacology*; D025401:Echocardiography, Stress / Q000379:methods*; D058625:End Stage Liver Disease / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies
chemical_list: D002316:Cardiotonic Agents; D004280:Dobutamine
keywords: coronary artery disease; left ventricular ejection fraction; liver transplantation; microvascular dysfunction