Research Article: The 2016 ASE/EACVI recommendations may be able to more accurately identify patients at risk for diastolic dysfunction in living donor liver transplantation

Date Published: April 23, 2019

Publisher: Public Library of Science

Author(s): Jaesik Park, Jiyoung Lee, Ami Kwon, Ho Joong Choi, Hyun Sik Chung, Sang Hyun Hong, Chul Soo Park, Jong Ho Choi, Min Suk Chae, Frank JMF Dor.

http://doi.org/10.1371/journal.pone.0215603

Abstract

The aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT).

A total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency.

The study population was largely male (68.3%), and the median age was 54 (49–59) years. The median model for end-stage liver disease score was 12 (6–22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations.

The 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group.

Partial Text

Diastolic dysfunction is a major component of cirrhotic cardiomyopathy and more frequently occurs than systolic dysfunction in patients with cirrhotic cardiomyopathy [1]. Diastolic dysfunction frequently leads to the development of heart failure and an increased risk for mortality [2,3]. Even in patients with mild diastolic dysfunction and a preserved ejection fraction (EF), there is an increased risk for cardiovascular events after surgery [4,5]. Because of peripheral vasodilation in patients with end-stage liver disease (ESLD), independent of etiology, latent cardiac dysfunction is masked at rest. An impairment of systolic or diastolic cardiac response is frequently present when a patient is stressed during and after surgery. As many as half of cirrhotic patients showed signs of diastolic dysfunction within the first week after liver transplantation (LT) [6,7]. More than 70% of patients who undergo LT suffer from one or more complications related to the heart after surgery [8].

The main findings of this study were that there was a predominant difference in the prevalence rate of diastolic dysfunction between the 2016 and 2009 recommendations in patients undergoing LDLT. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the 2016 and 2009 recommendations was poor. The proportion of patients with a high BNP level (> 100 pg/mL) during surgery decreased significantly in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction had a worse overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the 2016 and 2009 recommendations. In the 2009 recommendations, there was a significant difference in patient survival rate between the dysfunction and indeterminate groups; however, the difference was not significant according to the 2016 recommendations.

Clinical application of diastology according to the 2016 ASE/EACVI recommendations in patients who underwent LDLT resulted in a lower prevalence of indeterminate function and overt diastolic dysfunction, and a higher prevalence of normal diastolic function. Therefore, the concordance between previous and current recommendations was poor, which was caused by reclassification of the diastolic functional evaluation. The current 2016 classification may be able to more clearly identify patients at risk for diastolic dysfunction that may result from inclusion of TR velocity > 2.8 m/s. This finding was supported by the intraoperative BNP level, as a diastolic marker. Particularly, patients in the 2016 indeterminate group seem to require an evaluation of cardiac diastolic function more frequently than those in the 2009 indeterminate group, during and after surgery, because the 2016 indeterminate group included ill patients who most likely should be evaluated and treated like the diastolic dysfunction group. Additionally, this finding is not limited to patients undergoing LDLT, but also can be addressed in patients undergoing deceased donor LT [53,54]. The prognostic impact of patients with indeterminate diastolic function and overt diastolic dysfunction needs further investigation in patients who undergo LDLT.

 

Source:

http://doi.org/10.1371/journal.pone.0215603

 

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