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Impact of Pulmonary Hemodynamics on the Decision to Offer Liver Transplantation to Patients with Portopulmonary Hypertension

S. Morjaria

Daniel Grinnan


R. Stravitz

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Conference: 2012 International PHA Conference and Scientific Sessions

Release Date: 06.22.2012

Presentation Type: Abstracts

Morjaria S1, Grinnan D1, Stravitz R1

1. Virginia Commonwealth University, United States of America

BACKGROUNDPortopulmonary hypertension (POPH) is the presence of pulmonary arterial hypertension in patients with co-existing portal hypertension. While the mean pulmonary arterial pressure (mPAP) has correlated with survival following liver transplant and remains the usual criteria for deciding whether or not to offer transplantation, some have advocated that pulmonary vascular resistance (PVR) is a more accurate variable for predicting transplant success. Little is known about practice patterns of practitioners involved in the care of patients with POPH. Through the use of clinical vignettes, we aim to better define how hemodynamic parameters, as determined by right heart catheterization, influence a practitioner’s decision to offer transplantation.

METHODSWe developed a series of 3 clinical vignettes involving similar patients with POPH. Patient 1 had POPH with a low mPAP and PVR and is a positive control. Patient 2 had POPH with a high mPAP and PVR and is a negative control. Patient 3 had POPH with a high mPAP, but a low PVR. E-mail addresses of transplant hepatologists and liver transplant surgeons from major transplant centers in the United States were obtained through personal correspondence. Using GoogleDocs for distribution, responses were anonymous. Descriptive statistics were used to assess the responses to returned vignettes.

RESULTS: The vignette was sent to 305 clinicians, and 42 responses were obtained, for a response rate of 14%. All but one of the respondents felt that patient 1 should receive a transplant, and all of the respondents felt that patient 2 should not receive a transplant. These responses indicate that our respondents were familiar with usual guidelines for transplant referral in patients with POPH. The majority of respondents (57%) believed that a patient with high mPAP but low PVR (patient 3) should be offered transplant, while only 10% felt this patient should not receive a transplant. There was a high degree of uncertainty with patient 3, as 34% of respondents answered “I don’t know.”

CONCLUSION: mPAP has traditionally been the variable used to determine if a patient with POPH is eligible for liver transplantation. In this vignette study, the majority of respondents were willing to offer transplant to a patient with elevated mPAP if the PVR remained low, indicating a shift in practice patterns. As many patients with cirrhosis have a high cardiac output and resultant increase in pulmonary arterial pressure, focus on the PVR may improve our ability to identify patients for liver transplantation and to predict their outcomes.