Endovascular closure of a congenital extrahepatic portosystemic shunt for the treatment of hepatopulmonary syndrome in an infant

Congenital portosystemic shunts may result in the development of hepatopulmonary syndrome, typically presenting with progressive hypoxemia in later childhood. We describe a case of a 5-month-old male with heterotaxy with polysplenia presenting with new onset hypoxemia. Subsequent evaluation identified an extrahepatic portosystemic shunt arising from the confluence of the main portal and superior mesenteric veins draining into the left renal vein. To treat his hypoxemia and prevent future complications of shunting, the patient underwent a successful single-stage endovascular closure.

Hepatopulmonary syndrome: Case report of the evidence of intrapulmonary shunt on 99mTc-MAA scintigraphy and contrast transthoracic echocardiography

The hepatopulmonary syndrome (HPS) is characterized by arterial oxygenation defect induced by intrapulmonary vascular dilatations in the setting of liver disease. We report a 57-year-old woman with a history of liver cirrhosis presented with progressive cyanosis, exertional dyspnea and a dry cough. Oxyhemoglobin saturation was 88.5% on room air. Contrast transthoracic echocardiography (cTTE) and technetium-99m-macroaggregated albumin (99mTc-MAA) scintigraphy showed an intrapulmonary shunting and confirmed HPS.

Imaging in hepatopulmonary syndrome-case report. A multicenter approach during the coronavirus pandemic

A 60-year-old lady with alcoholic liver disease developed central cyanosis and orthodeoxia. A technetium-99m macro-aggregated albumin lung perfusion scan and contrast echocardiogram were performed. A 13% right to left shunt was calculated from the macro-aggregated albumin scan. There were more bubbles in the left heart than the right at the end of the contrast echocardiogram. Hepatopulmonary syndrome was therefore diagnosed. The patient had a liver transplant five days after these investigations. Further discussion about hepatopulmonary syndrome will be provided. Normally, macro-aggregated albumin scans are performed in few centers, however as this was at the height of the coronavirus pandemic, the scan needed to be performed locally to reduce the chance of the patient getting coronavirus. Local radiographers were remotely instructed on conducting the macro-aggregated albumin scan by a larger center to provide a timely and important investigation in a logistically difficult scenario.

Hepatopulmonary syndrome as the first and only manifestation of cirrhosis in a patient with hypopituitarism

Hepatopulmonary syndrome (HPS) is characterised by the development of intrapulmonary arteriovenous blood shunts and vascular dilatation with consequent hypoxaemia, usually in the context of end-stage liver disease (ESLD). The estimated incidence of HPS in ESLD has been reported to be 13%-47%. Chronic liver disease has been described in patients with hypothalamic-pituitary dysfunction, mainly in the form of non-alcoholic fatty liver disease due to metabolic syndrome, with occasional progression to cirrhosis. We report a challenging case of a 27-year-old man with a background of hypopituitarism with no known liver disease who presented with progressive dyspnoea and hypoxaemia and was eventually diagnosed with severe HPS.

Assessment of biventricular function in patients with hepatopulmonary syndrome

Cardiac function impairment in the setting of hepatopulmonary syndrome (HPS) in patients with end stage liver disease remains an issue of debate. The current study evaluated possible correlations between HPS and biventricular systolic function in patients with decompensated cirrhosis. Consecutive liver transplantation candidates with stable decompensated cirrhosis were prospectively evaluated. HPS was defined as the presence of an elevated alveolar-arterial oxygen gradient and intrapulmonary vasodilatation, detected by contrast enhanced echocardiography. HPS severity was determined based on arterial blood oxygen pressure values, while shunt size was assessed with a semi-quantitative method. Demographic, clinical and laboratory parameters were also prospectively collected. In total, 130 patients (mean age 56.5, M/F: 94/36, MELD score 14.6 ± 5.6) were enrolled, of whom 45 (34.6%) fulfilled the criteria for HPS diagnosis (mild: 57.7%, moderate: 33.3%, severe 4.4% and very severe 4.4%). Significantly lower absolute left ventricular (LV) global longitudinal strain (GLS) values (- 21.6 ± 2.3 vs. - 22.6 ± 2.5%, p = 0.041) were measured in patients with HPS compared to cirrhotic patients without HPS, while there was no statistically significant difference regarding right ventricular GLS (- 22.1 ± 3.3 vs. - 23.2 ± 3.5%, p = 0.061) between the two groups. Lower LV ejection fraction values were also recorded in the HPS group (53.9 ± 3.5 vs. 56.3 ± 4.5%, p < 0.01). No other echocardiographic parameter was correlated to HPS. Intrapulmonary shunt grading was correlated to HPS classification (χ² = 19.8, p < 0.01), with lower arterial oxygen values being recorded in higher stages of intrapulmonary shunt. In patients with cirrhosis, the presence of HPS is associated with worse LV contractile performance.

Hepatopulmonary syndrome-attributed extreme hypoxemia and polycythemia revealing liver cirrhosis

We report an unusual case of severe hepatopulmonary syndrome with previously unrecognized cirrhosis, presenting with acute on chronic dyspnoea, extreme hypoxemia, secondary polycythemia as well as direct identification of arteriovenous communications on computed tomography angiography. Hepatopulmonary syndrome, defined as the combination of hepatopathy, arterial deoxygenation and pulmonary vascular dilatation, is increasingly recognized as a life-threatening complication in advanced liver disease and transplant candidacy. It is usually diagnosed in chronic liver disease patients following pre-transplant evaluation or mild dyspnea investigation. Diagnosis relies on the indirect evidence of pulmonary arteriovenous communications suggested by echocardiography with a bubble study. Clinicians need to be aware of this rare but potential acute presentation at the emergency room.

Transoesophageal echocardiography during orthotopic liver transplantation

Despite the importance of haemodynamic management in patients undergoing liver transplantation, there is currently no consensus on the most appropriate type of monitoring to use. In this context, transoesophageal echocardiography can provide useful information to professionals, although their use constraints prevent further spread today.

Hepatopulmonary syndrome with large pulmonary arteriovenous malformations: CT findings with emphasis on its association with a mosaic pattern of the lung parenchyma

We present a case of a 54-year-old patient with cirrhosis, progressive dyspnea, and platypnea. Thoracic computed tomography (CT) showed multiple pulmonary arteriovenous malformations (PAVM), confirming the diagnosis of hepatopulmonary syndrome (HPS). Besides precisely identifying the number and location of PAVM, CT also demonstrated a striking mosaic pattern of the lung parenchyma, characterized by the presence of alternating geographic areas of low attenuation (showing pulmonary vessels with a decreased diameter) with regions of relatively increased attenuation (showing pulmonary vessels with a normal diameter). This mosaic pattern of the lung parenchyma has scarcely been described in patients with HPS since it is not always present and usually requires a post-processing of the CT images in order to increase the contrast between the low attenuation areas (representing hypoperfused regions) and the areas with a relatively increased attenuation (representing better perfused regions). The decision was made to embolize the major PAVM, achieving an improvement of both the oxygen partial pressure and the patient's symptoms. This improvement allowed the patient to become an acceptable candidate for liver transplantation. We believe that, unlike other radiological signs of HPS, the mosaic pattern has not been sufficiently described in the scientific literature. If the association of the mosaic pattern on CT with HPS is confirmed in larger studies, it could become a useful sign for detecting hypoperfused pulmonary areas related to small nonvisible PAVM.

Hepatopulmonary syndrome: What we know and what we would like to know

Hepatopulmonary syndrome (HPS) is characterized by abnormalities in blood oxygenation caused by the presence of intrapulmonary vascular dilations (IPVD) in the context of liver disease, generally at a cirrhotic stage. Knowledge about the subject is still only partial. The majority of the information about the etiopathogenesis of HPS has been obtained through experiments on animals. Reported prevalence in patients who are candidates for a liver transplantation (LT) varies between 4% and 32%, with a predominance of mild or moderate cases. Although it is generally asymptomatic it does have an impact on their quality of life and survival. The diagnosis requires taking an arterial blood gas sample of a seated patient with alveolar-arterial oxygen gradient (AaO₂) ≥ 15 mm Hg, or ≥ 20 mm Hg in those over 64 years of age. The IPVD are identified through a transthoracic contrast echocardiography or a macroaggregated albumin lung perfusion scan (^99mTc-MAA). There is currently no effective medical treatment. LT has been shown to reverse the syndrome and improve survival rates, even in severe cases. Therefore the policy of prioritizing LT would appear to increase survival rates. This paper takes a critical and clinical look at the current understanding of HPS, as well as the controversies surrounding it and possible future research.

[A man with slowly progressive dyspnea on exertion]

A 42-year-old man with a medical history of liver cirrhosis and portal hypertension was admitted to the hospital because of slowly progressive shortness of breath and hypoxemia. The diagnosis hepatopulmonary syndrome was confirmed by a pulmonary perfusion scan with 99m Tc-albumin. The scan showed a right-left shunt, because the 99m Tc-albumin transited the lungs and appeared in the brain, the thyroid gland, the kidneys and the spleen. The patient received a liver transplantation, which is considered the only definitive treatment.

Lung perfusion imaging in hepatopulmonary syndrome using (99m)Tc macroaggregated albumin

Hepatopulmonary syndrome is a serious pulmonary vascular complication in patients with chronic liver disease. It constitutes a triad of chronic liver disease, increased alveolar-arterial oxygen gradient, and evidence of intrapulmonary shunt (IPS). The diagnosis of IPS can be made by bubble echocardiography, technetium-99m-labeled macroaggregated albumin ((99m)Tc-MAA) scintigraphy or pulmonary arteriography. Though echocardiography is a sensitive screening test, MAA scintigraphy can also quantify the extent of shunting.

Screening of hepatopulmonary syndrome (HPS) with CEUS and pulse-oximetry in liver cirrhosis patients eligible for liver transplant

BACKGROUND AND AIM

The prevalence of hepatopulmonary syndrome (HPS) in the setting of cirrhosis ranges between 4%-47%. We aimed to detect a correlation between heart and lungs findings on contrast-enhanced ultrasound (CEUS)and pulse-oximetry, in order to early detect HPS and thus to improve patients referral to orthotopic liver transplantation(OLT).

METHODS

We considered at risk for HPS all patients with delayed left ventricle (LV) enhancement of the contrast agent,at least 3 systolic beats after it appears in the right ventricle(RV). We correlated CEUS results with pulse-oximetry findings,considering to have a positive HPS diagnosis in all patients with both CEUS findings and SaO2 95%.

RESULTS

From 186 patients diagnosed with liver cirrhosis, 56 patients (30.10%) had delayed LV enhancement of the contrast agent. Pulse-oximetry showed alterations, such as SaO2 95%and PaO2 70 mmHg in 62 patients (33.33%). Pearson index showed a good correlation between lung and heart CEUS findings and pulse-oximetry (r=0.99) in HPS diagnosis. CONCLUSIONS. Two non-invasive, simple and rapid methods such as CEUS and pulse-oximetry can easily diagnose HPS, a highly fatal complication of liver cirrhosis, and can also guide the future treatment by speeding up OLT recommendations.

Novel predictors of intrapulmonary vascular dilatations in cirrhosis: extending the role of pulse oximetry and echocardiography

BACKGROUND AND STUDY AIMS

Intrapulmonary vascular dilatations (IPVDs) are a criterion for the diagnosis of hepatopulmonary syndrome in patients with liver cirrhosis. We aimed to show that IPVDs are more common than suspected in a heterogenous cirrhotic population and to identify new diagnostic parameters.

PATIENTS AND METHODS

Forty-three consecutive patients with cirrhosis admitted to our Gastroenterology department were included in this prospective study. History, physical examination, ECG and, when warranted, pulmonary function tests and chest radiograph were used to exclude patients with significant cardiac or pulmonary disease. Contrast enhanced transthoracic echocardiography (CEE) was used to determine the presence of IPVDs. Pulse oximetry readings were taken in the supine and standing positions.

RESULTS

We found 12 patients with IPVDs. Statistical analysis proved the correlation between IPVDs and systolic pulmonary artery pressure (sPAP) (p= .049), right ventricle wall width (RVW) (p = .013) and E/A ratio (p = .034) but not left atrial or ventricular diameter. Orthodeoxia was also present more frequently in patients with positive CEE. The difference between supine and standing oxygen saturation (changeSat) proved a fair diagnostic test for detecting IPVDs, with an area under the receiver operated curve (AUROC) of 0.823.

CONCLUSIONS

Our study shows that RVW, sPAP, E/A and orthodeoxia determined by pulse oximetry are valuable novel predictors of IPVDs, encouraging the routine use of pulse oximetry and echocardiography in cirrhotic patients.

Selective internal radiation therapy of hepatocellular carcinoma: potential hepatopulmonary shunt reduction after sorafenib administration

Sorafenib, a protein kinase inhibitor, is a systemic drug that has been licensed for the treatment of hepatocellular carcinoma (HCC). This retrospective study assessed whether the administration of sorafenib can result in a reduction of the hepatopulmonary shunt (HPS) before selective internal radiation therapy (SIRT). After exclusion from SIRT because of high HPS, computed tomography scan indicated a shunt reduction in seven patients with HCC receiving sorafenib. Repeated measurements revealed HPS reduction (from 26.5% to 7.5% on average), and subsequent SIRT became possible. In conclusion, sorafenib may reduce HPS in patients with advanced HCC in some cases.

Saline contrast echocardiography in patients with hepatopulmonary syndrome awaiting liver transplantation

BACKGROUND

Patients with hepatopulmonary syndrome (HPS) with end-stage liver disease (ESLD) have higher cardiorespiratory mortality than those without. The aims of this study were to determine whether echocardiography could distinguish patients with ESLD with and without HPS and whether the diagnosis of HPS by contrast echocardiography (CE) was altered by the performance of the test in a supine or standing position.

METHODS

Subjects were recruited prospectively from patients with end-stage liver disease undergoing assessment for liver transplantation. Hepatopulmonary syndrome was diagnosed on the basis of arterial blood gas analysis, lung function testing and agitated saline contrast echocardiography in the absence of primary cardiac or pulmonary disease. Bubble contrast injections were performed supine or standing in a randomised order and read by a blinded observer.

RESULTS

CE showed late right-to-left shunting in 13 of 50 consecutive patients with cirrhosis (26%). Eight patients (16%) had definite diagnoses of HPS. CE in the standing position consistently increased both the number and the size of shunts compared with supine injection. CE detected intrapulmonary shunting before a change in arterial blood gases. Standard echocardiographic parameters did not distinguish between those with and without HPS.

CONCLUSION

This study suggests that screening for HPS in patients with advanced cirrhosis should be done using CE with patients in the upright position.

Prediction of intrapulmonary right to left shunt with left atrial size in patients with liver cirrhosis

BACKGROUND

We screened a large number of liver transplant candidates with contrast echocardiography to detect intrapulmonary right to left shunt (IPS). We found that IPS is frequently present in patients with left atrial enlargement. This finding raises a question concerning the correlation between IPS and left atrial size in patients with liver cirrhosis.

OBJECTIVES

The aim of this prospective study was to evaluate the possible correlation between left atrial size and IPS in patients with liver cirrhosis.

METHODS

Adult patients (>18 years old) with documented liver cirrhosis underwent trans-thoracic contrast echocardiography with agitated saline. Left atrial dimension was measured by M-mode echocardiography. Stroke volume was calculated using left ventricular M-mode echocardiography. Patients with atrial fibrillation, intracardiac shunt, congenital heart defects, valvular heart disease and diastolic dysfunction were excluded.

RESULTS

A total of 92 patients met all study criteria. Of these, 39 (42.3%) had IPS. Cardiac output was significantly greater in patients with IPS compared with those without IPS (5.68 +/- 0.83 L/min vs 4.75 +/- 0.76 L/min, P < 0.01). In a multi-variable model, after adjustment for body surface area and body mass index, left atrial enlargement was the strong predictor of IPS (area under the curve = 0.66) but when controlling for cardiac output, left atrial size was not an independent predictor of IPS.

CONCLUSION

In the context of liver cirrhosis, patients with IPS have greater cardiac output compared with those without shunt. Left atrial enlargement, which reflects one aspect of increased cardiac output, is an indirect marker of IPS and greater left atrial dimension is associated with the presence of intrapulmonary right-to-left shunt.

[Case of hepatopulmonary syndrome with no vascular dilation in chest CT]

A 69-year-old man afflicted with alcoholic liver cirrhosis complained of dyspnea on effort. His chest CT shows moderate emphysema, and no vascular dilation. An intrapulmonary shunt study using 99mTc-MAA revealed 43% shunt to whole body. Hepatopulmonary syndrome was diagnozed, and he was treated with home oxygen therapy. There is a possibility that the chest CT of patient with hepatopulmonary syndrome complicating emphysema shows no vascular dilation.

[A new method to obtain right-to-left shunt index of the lung using 99mTc-MAA pulmonary perfusion scintigraphy and first-pass dynamic data acquisition]

Generally a right-to-left shunt index in pulmonary area was calculated from total body and pulmonary area by scintillations count using 9mTc-MAA pulmonary perfusion scintigraphy. In this study, we devised a newly calculation method for right-to-left shunt index in pulmonary area from 9mTc-MAA pulmonary perfusion scintigraphy by first-pass dynamic data. We compared the proposed method with the conventional method in 26 patients (9 men and 17 women; 3-26 years old): 23 patients with congenital biliary atresia (CBA) post operation and the other 3 patients with right-to-left shunt from hepatopulmonary syndrome. As a result, there was a positive correlation of the index values between the proposed method and the conventional method (r = 0.929). Thus, the present method should be clinically useful.

Reversal of severe hepato-pulmonary syndrome in congenital hepatic fibrosis after living-related liver transplantation

We report a 5-year-old girl with congenital hepatic fibrosis who presented with clubbing and cyanosis. Partial pressure of oxygen was 40 mmHg with oxy-gen saturation of 70% on room air, which improved to 128 mmHg and 92% on inhalation of 100% oxygen. Macroaggregated albumin scan showed 58% shunting to the brain, suggestive of severe hepatopulmonary syndrome. Echocardiogram and pulmonary angiogram ruled out pulmonary hypertension. Four weeks after living-related liver transplantation, she had normal blood gases and reduction in shunting to 7% on macroaggregated albumin scan.

[Pulmonary complications of hepatic cirrhosis: portopulmonary hypertension and hepatopulmonary syndrome. The paradox of pulmonary vasoconstriction and vasodilation]

Cardiopulmonar complications in chronic liver diseases were described 100 years ago. Altough both hepatopulmonary sindrome and portopulmonary hypertension originates from liver damage, clinical findings and diagnosis are very different. These complications are important due to the highly deleterous impact on disease evolution and prognosis. Currently, there is not an ideal treatment for these diseases and liver transplantation should be adequately evaluated. In this review we analyze the most important issues on hepatopulmonary sindrome and portopulmonary hypertension. These complications,under the cornerstone of portal hypertension are characterized by pulmonary constriction and dilatation, respectively.

Left atrial volume: a novel predictor of hepatopulmonary syndrome

OBJECTIVES

We studied patients with hepato-pulmonary syndrome (HPS). We found that HPS is frequently present in patients with left atrial enlargement. The aim of this prospective study was to evaluate the possible correlation between left atrial volume and HPS.

METHODS

Adult patients (>18 yr old) with biopsy proven liver cirrhosis who were referred for liver transplantation were enrolled in the study. Diagnosis of HPS was established when the following points were fulfilled: (a) the presence of chronic liver disease, (b) increased alveolar-arterial difference (AaDO(2)), (c) intrapulmonary vascular dilatation, and (d) absence of primary cardiac or pulmonary disease.

RESULTS

We enrolled 41 patients (mean age 47.1 +/- 10.6 yr) diagnosed with HPS. Also 108 Child-Pugh score matched cirrhotic patients (mean age 49.2 +/- 9.3 yr) who have negative contrast echocardiography and normal age-related AaDO(2) were selected as a control group for the purpose of comparison of left atrial volume (LAV). LAV was significantly greater in patients with HPS compared to the control group (55.1 +/- 7.5 mL vs 37.1 +/- 9.3 mL, P < 0.05). The area under the receiver-operating characteristic (ROC) curve for LAV was 0.903 (Cut point >/= 50 mL, sensitivity 86.3%, specificity 81.2%).

CONCLUSION

In the context of liver cirrhosis, LAV >/= 50 mL is a simple and feasible parameter to detect HPS.

Hepatopulmonary syndrome and right ventricular diastolic functions: an echocardiographic examination

AIM

Liver functions are affected in the course of cardiac diseases, and similarly, liver diseases affect cardiac functions. Many studies in the literature have shown that left ventricular systolic and/or diastolic dysfunction may develop during chronic liver disease. However, there are limited studies investigating right ventricular functions during chronic liver diseases.

METHODS

A total of 84 patients who had no systolic and/or diastolic dysfunction in the left ventricle (LV) were evaluated; 46 patients with liver cirrhosis; 10 (21.74%) cirrhotic patients with hepatopulmonary syndrome (HPS) (group 1), 36 (78.26) cirrhotic patients without HPS (group 2), and 38 healthy individuals were treated as control.

RESULTS

Right ventricular diastolic dysfunction was determined in all patients of group 1 (100%), 26 of group 2 (72.22 %), and 4 of the controls (10.52%) (P<0.05). Tricuspid deceleration time (dt) was significantly different between the groups (P<0.05). In addition, right atrium (RA) diameters, right ventricle (RV) diameters, and RV wall thickness were significantly different between the groups (P<0.05). Pulmonary artery pressure (P<0.05) and pulmonary vascular resistance (P<0.05) were also seen to be higher in group 1 than those in group 2 and control group.

CONCLUSIONS

Right ventricular diastolic dysfunction rate is high in chronic liver diseases. In the presence of HPS, right ventricular diastolic dysfunction is more remarkable in patients than those without HPS. Right ventricular diastolic dysfunction may result in dilatation and hypertrophy in the right heart.

Value of contrast echocardiography for the diagnosis of hepatopulmonary syndrome

The hepatopulmonary syndrome must be suspected in patients with end-stage liver disease and refractory hypoxemia. We report a case of a 49-year-old woman with hypoxemia and cirrhosis referred to the cardiac ultrasound laboratory in the evaluation of liver transplantation. Contrast-enhanced echocardiography with intravenous injection of agitated saline solution was crucial to obtain the definitive diagnosis. This imaging modality has proven to be a valuable tool in detecting intrapulmonary right-to-left shunt. The present case emphasizes the usefulness of contrast echocardiography in the diagnosis of a noncardiac disease with important prognosis implications.

Gas exchange abnormalities in patients listed for liver transplantation

Abnormalities of pulmonary gas exchange are common in patients with advanced liver disease. Since arterial blood hypoxemia is an important issue in the preoperative evaluation of liver transplant candidates, the study was undertaken to determine the incidence and severity of lung function impairment with a special emphasis on pulmonary gas exchange abnormalities in this group of patients. 104 consecutive patients (47 F and 57 M, mean age 46 +/-11 yr) listed for orthotopic liver transplantation participated in this prospective study. All patients underwent evaluation including: clinical assessment (Child-Pough and MELD classification), chest X-ray, chest sonography, lung function tests, arterial blood gases measurement, and transthoracic contrast enhanced echocardiography. There were 2 patients with acute hepatic failure, 6 patients with primary or metastatic liver carcinoma, and 96 patients with chronic liver disease. The mean PaO(2) and lung function parameters for the entire group were within normal limits. There were 29 hypoxemic patients (PaO(2)< 80 mmHg) and 40 patients with widened (>20 mmHg) P(A-a)O(2). DL(CO) was significantly lower in cirrhotic vs. non-cirrhotic patients (76.5 +/-19.3 vs. 92.4 +/-19.0% predicted; P<0.001). Hepatopulmonary syndrome (HPS) was recognized in 23 (24%) patients. 91% of patients with HPS showed mild to moderate stage of disease. There were significant difference between differences HPS patients and non-HPS patients in DL(CO) (69.0 +/-14.5 vs. 83.5 +/-20.7, P<0.01). In conclusion, all patients referred for OLT should be screened for gas exchange abnormalities. Such a workup should include not only PAO(2) but also DL(CO) and P(A-a)O(2) measurement together with contrast enhanced echocardiography.

Echocardiographic detection of intrapulmonary shunting in a patient with hepatopulmonary syndrome: case report and review of the literature

Transthoracic echocardiography is a useful tool in the evaluation of patients with intrapulmonary and intracardiac shunts. We describe a case of a 49-year-old female with severe hypoxemia in the setting of aortic stenosis and cirrhosis of the liver. The use of agitated saline contrast during an echocardiography study helped to establish the diagnosis of intrapulmonary arteriovenous shunting consistent with the hepatopulmonary syndrome, thereby confirming the etiology of her symptoms and laboratory findings. This case report highlights the utility of echocardiography in diagnosing intrapulmonary shunts and assists in the understanding of the pathophysiology of hypoxemia in such patients.

Hepatopulmonary syndrome increases the postoperative mortality rate following liver transplantation: a prospective study in 90 patients

Hepatopulmonary syndrome (HPS) is a frequent pulmonary complication of patients with end-stage liver diseases. HPS is diagnosed by hypoxemia and pulmonary vascular dilatation and is an independent risk factor of mortality. Orthotopic liver transplantation (OLT) is the only factor that modifies the natural course of HPS. Once patients with HPS have been transplanted, their long-term survival rate is similar to transplanted patients without HPS. Consequently, HPS is an indication of OLT whatever the severity of hypoxemia. However, besides the favorable long-term survival of HPS patients with OLT, a high postoperative mortality (mostly within 6 months) has been suggested. The aim of our study was to analyze the incidence of HPS and postoperative outcome after OLT in 90 consecutive patients. All patients were prospectively included and had blood gas analysis to detect HPS. Patients with hypoxemia had contrast echocardiography to confirm HPS. Nine patients had HPS with a 50 </= PaO(2)</= 70 mmHg. Among them 3 (33%) died while the mortality rate was 9.2% in the group without HPS (7 over 76 patients). In the HPS patients who survived, the syndrome completely recovered within 6 months. In conclusion, our study shows a high postoperative mortality rate following OLT even though the preoperative PaO(2) was >50 mmHg in all HPS patients transplanted.

Reversion of severe hepatopulmonary syndrome in a non cirrhotic patient after corticosteroid treatment for granulomatous hepatitis: A case report and review of the literature

Hepatopulmonary syndrome (HPS) is defined as a clinical triad including liver disease, abnormal pulmonary gas exchange and evidence of intrapulmonary vascular dilatations. We report a 61-year-old male presented with fatigue, long-lasting fever, loss of weight, signs of portal hypertension, hepatosplenomegaly, cholestasis and progressive dyspnoea over the last year. Clinical, laboratory and histological findings confirmed the diagnosis of granulomatous hepatitis. HPS due to hepatic granuloma-induced portal hypertension was proved to be the cause of severe hypoxemia of the patient as confirmed by contrast-enhanced echocardiography. Reversion of HPS after corticosteroid therapy was confirmed by a new contrast-enhanced echocardiography along with the normalization of cholestatic enzymes and improvement of the patient’s conditions. This is the first case of complete reversion of HPS in a non-cirrhotic patient with hepatic granuloma, indicating that intrapulmonary shunt in liver diseases is a functional phenomenon and HPS can be developed even in miscellaneous liver involvement as in this case.

Evaluation of intrapulmonary vascular dilatations with high-resolution computed thorax tomography in patients with hepatopulmonary syndrome

GOALS

We aimed to determine the role of thorax high-resolution computed tomography (HRCT) in demonstrating the pulmonary vasodilatation in patients with hepatopulmonary syndrome (HPS).

BACKGROUND

Traditionally, the presence of intrapulmonary vascular dilatations can be detected by using one of the three diagnostic modalities: contrast-enhanced echocardiography, technetium 99 m-labeled macroaggregated albumin scan, and pulmonary angiography.

STUDY

The study group included 10 patients with HPS (Group 1), 12 patients with normoxemic cirrhosis (Group 2), and 12 healthy controls (Group 3). All of the subjects underwent conventional and HRCT of thorax. The diameters of pulmonary trunk, main pulmonary arteries, and right lower lobe basal segmental arteries were measured. The ratios of right lower lobe basal segmental pulmonary artery to bronchus diameter were calculated.

RESULTS

The mean diameters of the main pulmonary trunk, right and left main pulmonary arteries were not different between the groups. Mean diameters of right lower lobe basal segmental pulmonary arteries were significantly higher in Group 1 compared with Group 2 (P=0.01) and Group 3 (P=0.002). Mean right lower lobe basal segmental pulmonary artery to bronchus ratios were significantly higher in Group 1 compared with Group 2 (P=0.03) and Group 3 (P<0.001). Group 2 had significantly higher pulmonary artery to bronchus ratios than Group 3 (P<0.001).

CONCLUSIONS

Thorax HRCT may be helpful in the diagnosis of HPS by demonstrating the dilated peripheral pulmonary vessels or increased pulmonary artery to bronchus ratios in patients with liver disease and hypoxemia.

Hepatopulmonary syndrome can show spontaneous resolution: Possible mechanism of portopulmonary hypertension overlap?

Hepatopulmonary syndrome (HPS) (hypoxaemia due to intrapulmonary vasodilation and a right-to-left shunt associated with liver disease) resolves after liver transplantation. The authors describe a case of spontaneous resolution of HPS prior to liver transplantation. This patient was diagnosed with HPS associated with extra-hepatic biliary atresia when she was 10 years old. She exhibited digital clubbing, facial vascular dilation, cyanosis, and suffered from dyspnoea during exercise. The patient's PaO(2) at rest was 53.8 mm Hg in room air and a Technetium-99m macro-aggregated albumin lung perfusion scan demonstrated a right-to-left shunt. Although her symptoms and laboratory data supported a diagnosis of HPS, she nevertheless showed spontaneous resolution within 2 years. When she was 14 years old, pulmonary hypertension was evident upon examination of her echocardiogram. HPS may be improved or masked by an accidental overlap with pulmonary hypertension in the terminal stage of liver disease.

Hepatopulmonary syndrome: report of one case

Hepatopulmonary syndrome consists of a triad of chronic liver disease, hypoxemia, and intrapulmonary vascular dilatation in the absence of primary cardiac or pulmonary diseases. Though this complication has been described in as many as 4-29% of patients with liver disease, its clinical manifestations are often subclinical. The standard diagnostic tests for hepatopulmonary syndrome are the applications of contrast echocardiography and 99mTc lung perfusion scan. In this report, we describe a 19-year-old female with biliary atresia and subsequent liver cirrhosis, who also had the complication of hepatopulmonary syndrome since adolescence. We conclude when the symptoms and signs of hypoxemia appear in a patient with chronic liver disease, the differential diagnosis of hepatopulmonary syndrome should be kept in mind.

Natural history of hepatopulmonary syndrome: Impact of liver transplantation

Few data exist concerning survival after the diagnosis of hepatopulmonary syndrome (HPS). Although orthotopic liver transplantation (OLT) frequently results in complete resolution of HPS, the relationship between transplantation and survival has not been described. The study rationale was to describe long-term survival in patients with HPS. Data were derived from patients diagnosed with HPS at Mayo Clinic (n = 61) between 1985 and 2002, including those undergoing OLT (n = 24) and those who did not (n = 37). A case-control, Kaplan-Meier survival analysis between HPS patients and 77 patients without HPS matched for liver disease cause, model for end-stage liver disease (MELD), severity of liver disease by the Child classification, and age was described for OLT and non-OLT groups. Patients with HPS had a mean partial pressure of arterial oxygen (PaO(2)) decline of 5.2 + 2.3 mm Hg per year awaiting OLT. For HPS patients, despite similar baseline PaO(2), brain uptake of technetium macroaggregated albumin ((99m)TcMAA), or measures of hepatic dysfunction, 5-year survival associated with OLT was 76% versus 23% who did not undergo transplantation (P < .0001). Comparing those who did not undergo transplantation, HPS patients had worse 5-year survival than matched controls (P = .0003). However, reasons to deny OLT (comorbidity) in the setting of HPS may well have contributed to observed survival differences. Baseline PaO(2) </=50 mm Hg was associated with worse survival irrespective of the decision to perform OLT. In conclusion, hypoxemia of HPS is frequently progressive. As OLT outcome relates to pretransplantation PaO(2), additional MELD points should advance the priority for OLT in HPS.

Cirrhosis-related intrathoracic disease. Imaging features in 1038 patients

BACKGROUND/AIMS

To describe imaging features of cirrhosis-related intrathoracic disease.

METHODOLOGY

Chest CTs of 1038 cirrhotic patients (mean age 53 yrs; range, 17-79) were evaluated for: bronchoarterial ratio (BAR), arteriovenous malformations, interstitial opacities, emphysema, and pleural effusions. Lymphangiography, pulmonary angiography, cardiac ultrasound and scintigraphy were selectively performed.

RESULTS

Mean BAR was 0.83+/-0.19. In two patients with hepatopulmonary syndrome (HPS), mean BAR was 0.55. HRCT detected interstitial lung opacities in 15 patients. Signs of fibrosis were seen in 7 (only two associated to biliary cirrhosis) and interstitial edema in 8. Accurate pattern recognition was achieved in 10/15 cases (66.6%). Of the 93 patients with emphysema only one had documented alpha1-AT deficiency (1.08%). Multiple type 1 vascular dilatations were visualized in two patients with HPS. Hepatic hydrothorax was present in 49 patients (4.72%); right-sided in 34 (69.4%), bilateral in 9 (18.4%) and left-sided in 6 (12.2%). Hepatic chylothorax was confirmed in 3 patients. Lymphangiography demonstrated the site of leakage and the engorged thoracic duct.

CONCLUSIONS

CT can identify intrathoracic pathology associated with liver disease. Decreased BAR is highly specific for HPS. However, a multimodality approach is necessary to depict cases of liver origin.

Pulmonary blood transit time and impaired arterial oxygenation in patients with chronic liver disease

BACKGROUND

Contrast-enhanced echocardiography (CEE) using agitated saline can detect intrapulmonary vasodilatation (IPVD) in patients with hepatopulmonary syndrome (HPS). We estimated the pulmonary transit time of erythrocytes (PTT) by CEE, using microbubbles, and studied its relationship to arterial oxygenation in chronic liver disease.

METHODS

Sixteen patients with chronic liver disease and seven healthy subjects were studied. PTT was defined as the time between opacification of the right atrium and left atrium on CEE, using human serum albumin-air microbubble complexes with a mean diameter of 4 microm (Albunex). IPVD was detected by CEE with agitated saline. Arterial blood gases were analyzed with patients in the supine position, and while they were seated. Cardiac output (CO) was determined by Doppler echocardiography.

RESULTS

The mean PTT value for all of the patients was 4.0 +/- 1.4 s. One of the 3 patients who showed IPVD was normoxemic. Mild orthodeoxia was observed in the patients with abnormal alveolar-arterial oxygen difference (A-aDO2) values (>15 mmHg), but not in those with normal A-aDO2 values, or in the healthy subjects. PTT was correlated with PaO2 (r = 0.52; P < 0.05; n = 16) and A-aDO2 (r = -0.54; P < 0.05; n = 16) in the seated position. CO was significantly correlated with PTT (r = -0.62; P < 0.05; n = 15), but not with PaO2 and A-aDO2, in both positions.

CONCLUSIONS

PTT may be a useful parameter for evaluating arterial oxygenation in patients with chronic liver disease with early HPS.

Role of the chest radiograph in the preoperative assessment of the pulmonary function in patients with cirrhosis candidates to liver transplant

PURPOSE

To appraise the role of chest radiography (CXR) in the clinical assessment of pulmonary complications occurring as a result of liver disease of any cause, a standardised reading of CXR was compared both with the results of lung function studies and with the severity of liver disease in 60 consecutive patients with cirrhosis candidates to liver transplant.

MATERIALS AND METHODS

CXR were scored for signs of cardiomegaly, enlargement of central and or peripheral vessels, hyperkinetic circulatory and/or intravascular volume states, abnormally increased interstitial lung markings, and pleural effusion by three independent observers.

RESULTS

The CXR score of this complete vascular-interstitial deficiency showed a high interobserver reproducibility and was significantly increased in those patients with a more decompensated liver cirrhosis. Moreover, a larger number of CXR signs of vascular and interstitial deficiency was present in those patients who had a more severe cirrhosis (Child-Pugh class 3). Functional indices of pulmonary gas exchange and diffusing capacity were worse in patients with end-stage liver cirrhosis, and for some indices the correlation was statistically significant. The comparison between lung function and CXR score showed that on average lung function impairment was significantly less severe in patients with lower CXR scores.

CONCLUSIONS

In conclusion, the information derived from a standardised reading of CXR is valuable in the clinical assessment of the pulmonary damage induced by liver cirrhosis as it allows discrimination of classes of severity of liver disease and of lung function impairment. When integrated with physiologic measurements and, if necessary, with high resolution tomographic studies, chest radiography helps to discriminate patients with advanced liver cirrhosis and progressing towards a hepatopulmonary syndrome, who need a proper therapeutic management.

Characteristics and prevalence of intrapulmonary shunt detected by contrast echocardiography with harmonic imaging in liver transplant candidates

We investigated the prevalence and characteristics of intrapulmonary shunt using contrast echocardiography with harmonic imaging in 130 liver transplant candidates. We found a high prevalence of intrapulmonary shunts and a significant correlation between the degree of intrapulmonary shunt and the Child-Pugh classification score.

Hepatopulmonary Syndrome in HIV--Hepatitis C Virus Coinfection: A Case Report and Review of the Literature

A wide array of diagnoses must be considered when a patient with advanced liver disease and human immunodeficiency virus (HIV) infection presents with hypoxemia. It is important to entertain the possibility of hepatopulmonary syndrome (HPS) in such patients, a diagnosis that must be confirmed with a contrast-enhanced echocardiogram (bubble study). We describe a case of HPS diagnosed in a patient with HIV infection and chronic liver disease and review the literature on HPS.

Prognostic significance of the hepatopulmonary syndrome in patients with cirrhosis

BACKGROUND AND AIMS

The hepatopulmonary syndrome (HPS) has been defined by chronic liver disease, arterial deoxygenation, and widespread intrapulmonary vasodilation. Mortality of patients with HPS is considered to be high, but the effect of HPS on survival in patients with cirrhosis remains unclear.

METHODS

A total of 111 patients with cirrhosis were studied prospectively by using transthoracic contrast echocardiography for detection of pulmonary vasodilation, blood gas analysis, and pulmonary function test. Twenty different clinical characteristics and survival times were noted.

RESULTS

Twenty-seven patients (24%) had HPS. Their mortality was significantly higher (median survival, 10.6 months) compared with patients without HPS (40.8 mo, P < 0.05), even after adjusting for liver disease severity (2.9 vs. 14.7 months in Child-Pugh class C with [n = 15] and without HPS [n = 35, P < 0.05]; 35.3 vs. 44.5 months in Child-Pugh class B with [n = 7] and without HPS [n = 23, P = NS]), and exclusion of patients who underwent liver transplantation during follow-up (median survival 4.8 vs. 35.2 months, P = 0.005). Causes of death were mainly nonpulmonary and liver-related in the 19 patients with and the 35 patients without HPS who died. In multivariate analysis, HPS was an independent predictor of survival besides age, Child-Pugh class, and blood urea nitrogen. Mortality correlates with severity of HPS.

CONCLUSIONS

The presence of HPS independently worsens prognosis of patients with cirrhosis. This should influence patient management and scoring systems and accelerate the evaluation process for liver transplantation.

Hepatopulmonary syndrome in noncirrhotic portal hypertensive patients

Hepatopulmonary syndrome has yet not been sufficiently assessed in noncirrhotic portal hypertension. The prevalence of hepatopulmonary syndrome was determined in 31 consecutive patients with noncirrhotic portal hypertension (19 idiopathic portal hypertension, 7 portal vein thrombosis, 5 congenital hepatic fibrosis) and 46 patients with liver cirrhosis. Contrast echocardiography was carried out in all patients. Macroaggregated albumin lung perfusion scans were performed in patients with positive contrast echocardiogram. Hepatopulmonary syndrome was detected in 5 (10.8%) cirrhotic and 3 (9.7%) noncirrhotic portal hypertensive patients (2 idiopathic portal hypertension, 1 portal vein thrombosis). All patients with hepatopulmonary syndrome had an increased shunt fraction (13-62%) and a decreased diffusion capacity of carbon monoxide (40-79%), and 7 of them were hypoxemic (PaO2, 31.6-69.8 mm Hg). These findings show that hepatopulmonary syndrome may occur in both liver cirrhosis and noncirrhotic portal hypertension and that portal hypertension is the predominant etiopathogenic factor related to hepatopulmonary syndrome.

Hepatopulmonary syndrome: angiography and therapeutic embolization

We report a case where an embolization therapy was successfully performed for diffusely dilated pulmonary vessels in a patient with hepatopulmonary syndrome (HPS) as a palliative treatment before liver transplantation. To our knowledge, this therapeutic approach has been tried only for arteriovenous malformation type HPS, and not for diffuse dilatation [Chest 91 (1987) 920].

Quantitative lung perfusion scintigraphy and detection of intrapulmonary shunt in liver cirrhosis

OBJECTIVE

Frequent association between liver cirrhosis and hypoxemia has been well documented. It is mostly attributable to intrapulmonary shunt due to dilation of pulmonary vasculature. We performed quantitative lung perfusion scintigraphy to detect an intrapulmonary shunt in cirrhosis patients.

METHODS

Prior to injection, Tc-99m MAA was applied to thin layer chromatography for quality control. Three cirrhosis patients who had hypoxemia were examined as well as 11 control subjects. After i.v. injection of Tc-99m MAA, whole body anterior and posterior images were taken at 5 min in patients with cirrhosis and at 8 time points up to 60 min in control subjects. Regions of interest were placed at the bilateral lungs and the whole body, and pulmonary accumulation was calculated.

RESULTS

All the control subjects demonstrated more than 90% of radioactivity in the lungs until 20 min. In contrast, all the patients showed values less than 80% at 5 min. In the cirrhosis patients with hypoxemia, the presence of intrapulmonary shunt was confirmed on quantitative lung perfusion scan. In control subjects, pulmonary accumulation of Tc-99m MAA dropped as a function of time and became less than 90% after 30 min.

CONCLUSION

The timing of measurements is essential in evaluating intrapulmonary shunt.