Use of a pressure wire to evaluate right heart pressures in a pre-liver transplant recipient through a peripheral iv.
James F. Trotter M.D.
Schussler, J. M., S. K. Asrani, M. A. Ramsay and J. F. Trotter (2016). “Use of a pressure wire to evaluate right heart pressures in a pre-liver transplant recipient through a peripheral iv.” Liver Transpl 22(5): 695-697.
TO THE EDITOR: The pre–liver transplant cardiovascular evaluation of recipients routinely includes echocardiography to evaluate for the presence of pulmonary hypertension (pHTN), as patients with moderate or severe pHTN have significantly increased perioperative morbidity and mortality. A recent article by Khaderi et al.(1) suggested that portopulmonary hypertension carries even longer-term risks in post–liver transplant patients. It has become standard for patients in whom screening echocardiography suggests systolic pulmonary artery (PA) pressures >45 mm Hg to undergo confirmatory invasive testing with right heart catheterization (RHC). This allows for both confirmation of these findings, as well as initiation of treatment (where appropriate) for pHTN, and subsequent successful transplantation.(2,3) The direct assessment of a patient’s pulmonary pressures requires invasive instrumentation. In a large series of patients with pHTN, the overall risk of complication is approximately 1.1%, mostly due to the access site and bleeding risk.(4) In the general population, the presence of elevated international normalized ratio (INR) or thrombocytopenia increases the risk of invasive cardiac procedures and is a relative contraindication to heart catheterization. In end-stage liver disease patients, there are few data looking at the magnitude of the increased risk. Although there is a general assumption that this risk may be mitigated by administration of blood products (such as fresh frozen plasma or platelets), vitamin K, or recombinant factor VIIa, there are no data to support these maneuvers.(5) RHC has traditionally been performed using catheters up to 8 Fr in size, placed percutaneously through the internal jugular or common femoral vein. Smaller catheters, compatible with sheaths down to 5 Fr in size, make the potential for bleeding less, but there is always the possibility that bleeding complications (sometimes due to inadvertent arterial punctures) can occur when making a venous puncture. We describe the use of a novel pressure wire to easily and safely evaluate a patient’s pulmonary pressures without the need for additional venous punctures or blood products.