Karaciğer transplantasyon adayı hastalarda pulmoner hipertansiyon sıklığı ve portopulmoner hipertansiyonun retrospektif olarak değerlendirilmesi
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Date
2018
Authors
Bedir, Ömer
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Publisher
Uludağ Üniversitesi
Abstract
Portopulmoner hipertansiyon (PoPH), portal hipertansiyonun nadir görülen ancak mortalitesi yüksek pulmoner vasküler komplikasyonudur. Portal hipertansiyonu olan (karaciğer hastalığı eşlik etsin veya etmesin) hastalarda sağ kalp kateterizasyonuyla ölçülen ortalama pulmoner arter basıncı (oPAB)≥25 mmHg, pulmoner vasküler direnç (PVD)≥240 dynes.s.cm−5 (3 WU) ve pulmoner arter uç basıncı (PAUB)≤15 mmHg olması PoPH için tanı koydurucudur. Sağ kalp kateterizasyonu sonucunda 25≤oPAB<35 mmHg olması hafif, 35≤oPAB<45 mmHg olması orta, oPAB≥45 mmHg olması ciddi PoPH olduğunu gösterir. Karaciğer nakli planlanan hastalarda orta-ciddi derecede PoPH olması intraoperatif ve perioperatif mortalite artışıyla ilişkilidir. Bu nedenle hastalar PoPH tanısı açısından sistematik bir şekilde değerlendirilmelidir. Bu hastaların ekokardiyografiyle taranması, sağ kalp kateterizasyonu ile PoPH tanısının kesinleştirilmesi gerekir. Orta ve ciddi PoPH tanısı konulan hastalara pulmoner arteriyel hipertansiyon (PAH) spesifik tedavi sonrasında oPAB<35 mmHg olduğunda karaciğer nakli yapılması önerilmektedir. Bu çalışmanın amacı karaciğer nakil hazırlığı yapılan hastaların pulmoner hipertansiyon ve portopulmoner hipertansiyon açısından retrospektif olarak değerlendirilmesidir. Karaciğer nakil hazırlığı kapsamında 2007 ile 2017 yılları arasında operasyon öncesinde ekokardiyografi ile değerlendirilen 432 hasta çalışmamıza dahil edildi. Yapılan ekokardiyografide pulmoner hipertansiyondan şüphelenilen veya sistolik pulmoner arter basıncı (sPAB)≥40 mmHg olan hastalara sağ kalp kateterizasyonu yapıldı. Sağ kalp kateterizasyonuyla ölçülen oPAB, PAUB, kardiyak debi (KD) ve PVD verilerine göre PoPH tanısı konuldu. Karaciğer sirozu hastalarında pulmoner arter basıncı yüksekliğine neden olabilecek muhtemel durumlardan olan hiperdinamik dolaşım ve volüm yüklenmesi yine bu verilerle belirlendi. Çalışmaya dahil edilen 432 hasta içerisinden sağ kalp kateterizasyonu yapılan hasta sayısı 53 idi. Bu hastalardan 23'ünde sağ kalp kateterizasyonu ile ölçülen oPAB≥25 mmHg idi. 13 hastanın 8'inde volüm yüklenmesine bağlı, 5 hastada ise hiperdinamik dolaşıma bağlı olarak oPAB yüksekti. oPAB≥25 mmHg olan 8 hastaya ise PoPH tanısı konuldu. 5 hastaya hafif PoPH (25≤oPAB<35 mmHg), 1 hastaya orta PoPH (35≤oPAB<45 mmHg) ve 2 hastaya da ciddi PoPH (oPAB≥45 mmHg) tanısı konuldu. Hafif PoPH tanısı konulan hastalar karaciğer nakil sırasına alındı ve bu hastalardan 2'sine başarılı karaciğer nakli yapıldı. Orta veya ciddi PoPH tanısı konulan 3 hastaya ise PAH spesifik tedavi başlandı. Çalışmamızda pulmoner hipertansiyon sıklığı %4,8, PoPH sıklığı ise %1,8 olarak bulundu. Çalışmamızda, sağ kalp kateterizasyonu yapmak için ekokardiyografide sPAB için eşik değer 40 mmHg olarak alındı ve bu eşik değere göre PoPH tanısı için sensitivite %88,5, spesifite %88,6, pozitif prediktif değer %12 ve negatif prediktif değer %99,7 olarak bulundu. Sonuç olarak PoPH portal hipertansiyonun önemli bir komplikasyonudur. Portal hipertansiyonu olan hastalarda pulmoner arter basınç yüksekliği PoPH dışında; volüm yüklenmesi ve hiperdinamik duruma bağlı olarak da gelişebilmektedir. Tanının kesinleştirilmesi ve hastaların karaciğer nakline uygunluğunun belirlenmesi açısından sağ kalp kateterizasyonu yapılmalıdır.
Portopulmonary hypertension (PoPH) is a rare pulmonary vascular complication of portal hypertension that is related to high mortality rate. In the setting of portal hypertension (with or without liver disease), PoPH is diagnosed when mean pulmonary artery pressure (mPAP)≥25 mmHg, pulmonary vascular resistance (PVR)≥240 dynes.s.cm−5 (3 wood units) and pulmonary capillary wedge pressure (PCWP)≤15 mmHg. In right heart catheterization, if mPAP is lower than 35 mmHg it is defined as mild PoPH, if mPAP is greater than 45 mmHg is defined as severe PoPH. Moderate PoPH is that mPAP is between 35 mmHg and 45 mmHg. Moderate to severe PoPH in liver transplantation candidates is associated with increased intraoperative and perioperative mortality rate. Thus, these patients should be assessed systematically for PoPH. These patients should be screened with echocardiography for pulmonary hypertension and referred to right heart catheterization for the confirmation of PoPH diagnosis. After PAH-specific therapy for moderate to severe PoPH, patients with mPAP<35 mmHg are suggested to have liver transplantation safely. In the present study, it is aimed to evaluate the liver transplant candidates retrospectively in terms of pulmonary hypertension and portopulmonary hypertension. Four hundred-thirty two patients with preoperative echocardiographic evaluation from 2007 to 2017 were included in this study. Right heart catheterization was performed to the patients suspected for pulmonary hypertension in echocardiographic evaluation. PoPH diagnosis was made according to hemodynamic parameters such as mPAP, PCWP, cardiac output (CO), PVR measured via right heart catheterization. Hyperdinamic state and volume overload, which are possible causes of pulmonary arterial hypertension in cirrhosis, were also measured. Right heart catheterization was performed to 53 of 432 patients. In 23 of 53 patients, mPAP was greater than 25 mmHg. Hyperdynamic state, volume overload, and PoPH were diagnosed in 5, 8, and 8 patients, respectively. Two patients had severe, and one patient had moderate PoPH. Five patients with mild PoPH were listed for liver transplantation and two of them underwent liver transplantation safely. Pulmonary arterial hypertension (PAH)-specific therapy was started to 3 patients with moderate or severe PoPH. In our study, the prevalence of pulmonary hypertension was found 4.8% and the prevalence of PoPH was found 1.8%. We determined cut-off systolic pulmonary arterial hypertension (sPAP) value as 40 mmHg in echocardiographic evaluation to perform right heart catheterization. For this cut off value, sensitivity, specificity, positive predictive value, and negative predictive value were estimated as 88.5%, 88.6%, 12%, and 99.7%, respectively. In conclusion, PoPH is an important complication of portal hypertension. Besides PoPH, pulmonary hypertension can also be associated with volume overload or hyperdynamic states in the setting of portal hypertension. Right heart catheterization should be performed to confirm the PoPH diagnosis and determine whether the patient is appropriate candidate for liver transplantation or not.
Portopulmonary hypertension (PoPH) is a rare pulmonary vascular complication of portal hypertension that is related to high mortality rate. In the setting of portal hypertension (with or without liver disease), PoPH is diagnosed when mean pulmonary artery pressure (mPAP)≥25 mmHg, pulmonary vascular resistance (PVR)≥240 dynes.s.cm−5 (3 wood units) and pulmonary capillary wedge pressure (PCWP)≤15 mmHg. In right heart catheterization, if mPAP is lower than 35 mmHg it is defined as mild PoPH, if mPAP is greater than 45 mmHg is defined as severe PoPH. Moderate PoPH is that mPAP is between 35 mmHg and 45 mmHg. Moderate to severe PoPH in liver transplantation candidates is associated with increased intraoperative and perioperative mortality rate. Thus, these patients should be assessed systematically for PoPH. These patients should be screened with echocardiography for pulmonary hypertension and referred to right heart catheterization for the confirmation of PoPH diagnosis. After PAH-specific therapy for moderate to severe PoPH, patients with mPAP<35 mmHg are suggested to have liver transplantation safely. In the present study, it is aimed to evaluate the liver transplant candidates retrospectively in terms of pulmonary hypertension and portopulmonary hypertension. Four hundred-thirty two patients with preoperative echocardiographic evaluation from 2007 to 2017 were included in this study. Right heart catheterization was performed to the patients suspected for pulmonary hypertension in echocardiographic evaluation. PoPH diagnosis was made according to hemodynamic parameters such as mPAP, PCWP, cardiac output (CO), PVR measured via right heart catheterization. Hyperdinamic state and volume overload, which are possible causes of pulmonary arterial hypertension in cirrhosis, were also measured. Right heart catheterization was performed to 53 of 432 patients. In 23 of 53 patients, mPAP was greater than 25 mmHg. Hyperdynamic state, volume overload, and PoPH were diagnosed in 5, 8, and 8 patients, respectively. Two patients had severe, and one patient had moderate PoPH. Five patients with mild PoPH were listed for liver transplantation and two of them underwent liver transplantation safely. Pulmonary arterial hypertension (PAH)-specific therapy was started to 3 patients with moderate or severe PoPH. In our study, the prevalence of pulmonary hypertension was found 4.8% and the prevalence of PoPH was found 1.8%. We determined cut-off systolic pulmonary arterial hypertension (sPAP) value as 40 mmHg in echocardiographic evaluation to perform right heart catheterization. For this cut off value, sensitivity, specificity, positive predictive value, and negative predictive value were estimated as 88.5%, 88.6%, 12%, and 99.7%, respectively. In conclusion, PoPH is an important complication of portal hypertension. Besides PoPH, pulmonary hypertension can also be associated with volume overload or hyperdynamic states in the setting of portal hypertension. Right heart catheterization should be performed to confirm the PoPH diagnosis and determine whether the patient is appropriate candidate for liver transplantation or not.
Description
Keywords
Karaciğer nakli, Ekokardiyografi, Sağ kalp kateterizasyonu, Pulmoner hipertansiyon, Portopulmoner hipertansiyon, Liver transplantation, Echocardiography, Right heart catheterization, Pulmonary hypertension, Portopulmonary hypertension.
Citation
Bedir, Ö. (2018). Karaciğer transplantasyon adayı hastalarda pulmoner hipertansiyon sıklığı ve portopulmoner hipertansiyonun retrospektif olarak değerlendirilmesi. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.