Transient decrease in B-type natriuretic peptide level after liver transplantation does not ensure favorable post-transplant 30-day outcomes

Background@#High B-type natriuretic peptide (BNP) levels within the first 3 postoperative days (postBNPPOD3) after liver transplantation (LT) are greatly predictive of the 30-day mortality. We evaluated clinical impact of transient decrease in postBNPPOD3 compared to pretransplant BNP (preBNP) level on mortality and major adverse cardiac event (MACE) within 30 days after LT. @*Methods@#We retrospectively evaluated 3,811 LT patients who measured delta BNP (deltaBNP), defined by serial postBNPPOD3 minus preBNP. Thirty-day all-cause mortality and MACE were estimated in patients with deltaBNP 0 (n = 3,217, 84.4%), respectively. Kaplan-Meier survival and multivariable Cox regression analysis were used. @*Results@#Within 30 days, 100 (2.6%) of all patients died. Unexpectedly, 30-day mortality rate (6.1% [95% CI: 4.2–8.4%] vs. 2.0% [95% CI: 1.5–2.5%], P 0, respectively. Patients with deltaBNP < 0 had higher preBNP level (median [interquartile range], 251 [118, 586] vs. 43 [21, 92] pg/ml, P < 0.001) and model for end-stage liver disease score (26 [14, 37] vs. 14 [9, 23], P < 0.001) and more transfused intraoperatively. DeltaBNP < 0 remained significant after adjustments for potential confounders in multivariable analysis of 30-day mortality and MACE. @*Conclusions@#DeltaBNP < 0 within the first 3 postoperative days is mainly attributed to pre-LT severe liver and cardiac disease status, therefore, transient decrease in BNP level after LT does not ensure favorable post-LT 30-day outcomes.

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation / 대한마취과학회지

Background@#Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. @*Methods@#We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis. @*Results@#Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001). @*Conclusions@#Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation / 대한마취과학회지

Background@#Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. @*Methods@#We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis. @*Results@#Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001). @*Conclusions@#Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Systolic anterior motion of mitral chordae tendineae: prevalence and clinical implications in liver transplantation

Background@#Although systolic anterior motion (SAM) of the mitral valve anterior leaflet is well-known to cause hemodynamic perturbation in many anesthetic situations, the prevalence and clinical implication of SAM of mitral chordae tendineae (chordal SAM) in liver transplantation (LT) has not been evaluated. We aimed to assess the impact of chordal SAM on intraoperative postreperfusion syndrome and short and long-term all-cause mortality. @*Methods@#We retrospectively evaluated 1751 LT recipients from January 2011 to June 2017 who had preoperative echocardiography. Echocardiography-derived parameters and the prevalence of post-reperfusion syndrome between those with chordal SAM and without chordal SAM were compared. The cumulative mortality rate according to the presence of chordal SAM was evaluated by the Kaplan-Meier survival curve. @*Results@#Of the enrolled recipients, 21 (1.2%) had chordal SAM in preoperative echocardiography. Compared to those without chordal SAM, patients with chordal SAM had a smaller end-systolic volume index (median 18 ml/m2 vs. 22 ml/m2, P = 0.015) and end-diastolic volume index (median 52 ml/m2 vs. 63 ml/m2, P = 0.011). However, there was no difference in systolic and diastolic function in echocardiography. The prevalence of intraoperative post-reperfusion syndrome did not show any difference (42.9% vs. 45.3%, P = 1.000). Over the mean 4.8-year follow-up, cumulative 90-day and overall mortality also did not show a difference (Log rank P > 0.05, both). @*Conclusions@#Preoperative screening of echocardiography in LT recipients detects 1.2% of chordal SAM. It is found with small left ventricular volume, but is not related with intraoperative post-reperfusion syndrome and short- and long-term postoperative all-cause mortality in LT.

Preoperative echocardiographic evaluation of cardiac systolic and diastolic function in liver transplant recipients with diabetes mellitus: a propensity-score matched analysis

BACKGROUND: Diabetes mellitus (DM) increases risk of heart failure. It has been shown that diabetes leads to DM-cardiomyopathy, characterized by systolic and diastolic dysfunction. Pre-transplant diastolic dysfunction, has been associated with poor graft outcome and mortality. We assessed the hypothesis that end-stage liver disease (ESLD) patients with diabetes (DM-ESLD), have more advanced cardiac systolic and diastolic dysfunction, compared to ESLD patients without diabetes (Non DM-ESLD).METHODS: We retrospectively evaluated preoperative echocardiography of 1,319 consecutive liver transplant recipients (1,007 Non DM-ESLD vs. 312 DM-ESLD [23.7%]) January 2012–May 2016. Systolic and diastolic indices, such as left ventricular ejection fraction, transmital E/A ratio, tissue doppler s′, e′ velocity, and E/e′ ratio (index of left ventricular end-diastolic pressure), were compared using 1:2 propensity-score matching.RESULTS: DM-ESLD patients showed no differences in systolic indices of left ventricular ejection fraction and s′ velocity, whereas diastolic indices of E/A ratio ≤ 1 (49.0% vs. 40.2% P = 0.014), e′ velocity (median = 7.0 vs. 7.4 cm/s, P < 0.001) and E/e′ ratio (10.9 ± 3.2 vs. 10.1 ± 3.0, P < 0.001), showed worse diastolic function compare with Non DM-ESLD patients, respectively.CONCLUSIONS: DM-ESLD patients suffer higher degree of diastolic dysfunction compared with Non DM-ESLD patients. Based on this, careful preoperative screening for diastolic dysfunction in DM-ESLD patients is encouraged, because poor transplant outcomes have been noted in patients with preoperative diastolic dysfunction.

Recurrent ST segment elevations in a patient with asymptomatic early repolarization during head and neck surgery: implications of vasospastic angina

A 57-year-old woman scheduled for cochlear implant removal exhibited preoperative electrocardiographic findings of early repolarization (ER). Four episodes of transient ST segment elevations during surgery raised suspicion for vasospastic angina (VA). In the post-anesthetic care unit, the patient complained of chest discomfort and received sublingual nitroglycerin with uncertain effect. The patient refused to proceed with postoperative invasive coronary angiography, resulting in inconclusive diagnosis. Intraoperative circumstances limit the diagnosis of VA, which emphasizes the need for further testing to confirm the diagnosis. When VA is suspected in patients with underlying ER, it is reasonable to consider invasive examination to establish the diagnosis and prevent recurrence of VA. If ST changes are observed during surgery in patients with preoperative ER, careful monitoring is recommended. Due to general anesthesia, the absence of patient symptoms limits the definitive diagnosis of those with suspected VA. Therefore, additional postoperative surveillance is recommended.

Cardiovascular dysfunction and liver transplantation / 대한마취과학회지

Cardiovascular complications have emerged as the leading cause of death after liver transplantation, particularly among those with advanced liver cirrhosis. Therefore, a thorough and accurate cardiovascular evaluation with clear comprehension of cirrhotic cardiomyopathy is recommended for optimal anesthetic management. However, cirrhotic patients manifest cardiac dysfunction concomitant with pronounced systemic hemodynamic changes, characterized by hyperdynamic circulation such as increased cardiac output, high heart rate, and decreased systemic vascular resistance. These unique features mask significant manifestations of cardiac dysfunction at rest, which makes it difficult to accurately evaluate cardiovascular status. In this review, we have summarized the current knowledge of heart and liver interactions, focusing on the usefulness and limitations of cardiac evaluation tools for identifying high-risk patients.

The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration / 대한마취과학회지

BACKGROUND: The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration. METHODS: A total of 140 adult patients were randomized into 4 groups to receive either 30 microg/kg ephedrine (Group 30, n = 35), 70 microg/kg ephedrine (Group 70, n = 35), 110 microg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration. RESULTS: An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 +/- 44.7 s, Group 70: 152.6 +/- 40.3 s, Group 110: 151.2 +/- 51.6 s) compared to Group C (224.6 +/- 56.9 s) after 0.15 mg/kg of cisatracurium (P 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups. CONCLUSIONS: We conclude that pre-treatment with ephedrine 70 microg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects.