Perioperative risk predictors of cardiac outcomes in patients undergoing liver transplantation surgery.

BACKGROUND: Cardiac risk assessment for perioperative outcomes of liver transplantation patients is limited. We examined the outcomes of an older intermediate-cardiac-risk group of patients undergoing liver transplantation surgery. METHODS AND RESULTS: Patients who had liver transplantation surgery between 2001 and 2005 were studied. The 3 outcomes analyzed were nonfatal myocardial infarction, death, and either outcome within the first 30 days after the liver transplantation surgery. Of 403 patients (mean age, 52+/-9 years; 67% male), 106 (26%) were diabetic, 84 (21%) were hypertensive, and 173 (43%) had a history of smoking. There were 48 total events (12%), 25 myocardial infarctions (7%), and 38 deaths (9%) recorded during the perioperative period. From the final multivariate model, history of coronary artery disease, prior stroke, and postoperative sepsis predicted greater risk (P=0.014; odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3 to 11.8; P=0.025; OR, 6.6; 95% CI, 1.3 to 33.8; and P<0.001; OR, 7.5; 95% CI, 3.3 to 17.1, respectively). Use of perioperative beta-blockers was protective (P=0.004; OR, 0.20; 95% CI, 0.1 to 0.6) for combined cardiac outcomes. For the outcome of death on multivariate analysis, postoperative sepsis and increased interventricular septal thickness predicted risk (P<0.001; OR, 8.6; 95% CI, 3.5 to 20.9; and P=0.027; OR, 2.8; 95% CI, 1.1 to 7.2, respectively), whereas the use of perioperative beta-blockers was again protective (P=0.012; OR, 0.07; 95% CI, 0.01 to 0.56). CONCLUSIONS: In our study of cardiac risk assessment for liver transplantation surgery, history of stroke, coronary artery disease, postoperative sepsis, and increased interventricular septal thickness were markers of adverse perioperative cardiac outcomes, whereas use of perioperative beta-blockers was significantly protective.

Stress-induced wall motion abnormalities with low-dose dobutamine infusion indicate the presence of severe disease and vulnerable myocardium.

BACKGROUND: Patients with left ventricular (LV) systolic dysfunction due to coronary artery disease (CAD) may develop stress-induced wall motion abnormalities (SWMA) with low-dose (10 microg/kg/min) dobutamine infusion. The clinical significance of low-dose SWMA is unknown. OBJECTIVE: We investigated the clinical, hemodynamic and angiographic correlates of low-dose SWMA in patients with chronic ischemic LV systolic dysfunction. METHODS: Seventy patients with chronic ischemic LV systolic dysfunction who had dobutamine stress echocardiography were studied. Clinical, hemodynamic, and angiographic parameters at rest and low-dose were compared between 38 patients (mean ejection fraction (EF) of 30 +/- 8%) with low-dose SWMA and 32 patients (EF 30 +/- 11%) without low-dose SWMA. RESULTS: Multivariate analysis showed that the number of coronary territories with severe disease (stenosis > or =70%)(P = 0.001, RR = 6.3) was an independent predictor of low-dose SWMA. An increasing number of collateral vessels protected patients from low-dose SWMA (P = 0.011, RR = 0.25). A higher resting heart rate was a negative predictor of low-dose SWMA (P = 0.015, RR = 0.92) but no other hemodynamic variables were predictors. In the patients with low-dose SMA, regions with low-dose SWMA were more likely to be supplied by vessels with severe disease than regions without low-dose SWMA (92% vs 58%, P < 0.001). CONCLUSION: In patients with ischemic LV systolic dysfunction, the extent of severe disease and a lower numbers of collaterals predict the occurrence of low-dose SWMA. Low-dose SWMA is a highly specific marker for severe disease.