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Efficiency of the vasoconstrictor response to vascular exclusion in patients with alcoholic cirrhosis undergoing liver transplantation
Efficiency of the Vasoconstrictor Response to Vascular Exclusion in Patients With Alcoholic Cirrhosis Undergoing Liver Transplantation F. Acosta, T. Sansano, C.G. Palenciano, M. Reche, V. Roques, R. Beltran, R. Robles, F.S. Bueno, P. Ramirez, and P. Parrilla
A
LTERATIONS in the autonomic nervous systems lead to heart and circulation disorders that occur in cirrhosis.1 During orthotopic liver transplantation (OLT), the vascular exclusion of the liver in the anhepatic phase requires an important vasoconstrictor response to maintain arterial pressure. Our aim was to determine whether the characteristics of this response differ between patients with alcoholic and nonalcoholic etiology. PATIENTS AND METHODS We studied 60 cirrhotic patients undergoing OLT divided into two groups: group A (n ⫽ 38), patients diagnosed with alcoholic cirrhosis; and group B (n ⫽ 22), patients diagnosed with nonalcoholic cirrhosis. To discover beforehand the need of venovenous bypass (VVBP), we performed trial clamping (TC) of the infrahepatic vena cava and portal vein during the dissection phase. We performed a complete hemodynamic profile using a pulmonary artery catheter before (pre-TC) and 5 minutes after (post-TC) the start of TC. We indicated VVBP when the systolic arterial pressure did not exceed 100 mm Hg during TC. The following measure-
ments or calculations were made: heart rate (HR); mean arterial and pulmonary artery pressures (MAP, MPAP); central venous and pulmonary capillary wedge pressures (CVP, PCWP); cardiac index (CI); right and left ventricular stroke work indexes (RVSWI, LVSWI); and pulmonary and systemic vascular resistance indexes (PVRI, SVRI).
Statistics Student’s t and chi-square tests were used. Significance was set at P ⬍ .05.
RESULTS
We found no differences between the groups for ChildPugh grade or for indication of VVBP: six patients in group From the Liver Transplant Unit, University Hospital “V.Arrixaca,” Murcia, Spain. Address reprint requests to Dr Francisco Acosta, San Cristo´bal, 4 (3B), 30001-Murcia, Spain.
Table 1. Hemodynamic Changes With TC in Cirrhotic Patients
HR (beats/min) MAP (mm Hg) MPAP (mm Hg) CVP (mm Hg) PCWP (mm Hg) CI (L/min 䡠 m2) RVSWI (g/m 䡠 m2) LVSWI (g/m 䡠 m2) PVRI (dyn 䡠 s/cm5m2) SVRI (dyn 䡠 s/cm5m2)
Group
Pre-TC
Post-TC
Change (%)
A B A B A B A B A B A B A B A B A B A B
93.0 ⫾ 16.6 87.1 ⫾ 15.2 78.5 ⫾ 13.7 77.6 ⫾ 14.9 19.2 ⫾ 5.5 18.6 ⫾ 3.7 8.3 ⫾ 3.6 9.0 ⫾ 2.1 13.2 ⫾ 3.9 12.7 ⫾ 2.8 5.3 ⫾ 1.2 5.1 ⫾ 1.0 7.8 ⫾ 3.3 8.0 ⫾ 3.1 51.3 ⫾ 12.0 48.1 ⫾ 11.9 91.2 ⫾ 23.7 96.7 ⫾ 28.3 1150 ⫾ 308 1087 ⫾ 322
101.2 ⫾ 17.4 97.4 ⫾ 16.8† 74.3 ⫾ 12.6 72.7 ⫾ 13.8 13.8 ⫾ 4.7* 12.9 ⫾ 3.3# 5.4 ⫾ 1.9* 5.8 ⫾ 2.2# 8.9 ⫾ 1.6* 8.6 ⫾ 2.7# 2.9 ⫾ 0.9* 2.6 ⫾ 0.8* 3.2 ⫾ 1.4* 2.8 ⫾ 1.9* 26.1 ⫾ 8.4* 24.0 ⫾ 7.9* 138.6 ⫾ 49.8# 168.1 ⫾ 58.3# 1866 ⫾ 410* 1922 ⫾ 436* †
9 12 ⫺6 ⫺7 ⫺28 ⫺31 ⫺35 ⫺37 ⫺32 ⫺34 ⫺45 ⫺49 ⫺59 ⫺65 ⫺49 ⫺51 52 74 63 76
See text for abbreviations. Values expressed as mean ⫾ SD. † P ⬍ .05, #P ⬍ .01, and *P ⬍ .001 vs Pre-TC.
0041-1345/00/$–see front matter PII S0041-1345(00)01831-5
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2662
Transplantation Proceedings, 32, 2662–2663 (2000)
VASOCONSTRICTOR RESPONSE
2663
A and four in group B. All the hemodynamic variables compared were modified after TC except MAP, although we found no differences between the groups for any of them (Table 1).
altered humoral and/or reflex mechanisms,4,5 but as mentioned in previous studies,6,7 we cannot confirm an impaired myocardial contractility.
DISCUSSION
REFERENCES
An altered cardiovascular responsiveness to head-up tilting in patients with nonalcoholic cirrhosis has recently been shown.2,3 In our series the response to TC does not differ according to the etiology of the cirrhosis. We observe that the decrease in CI is similar to that found by Delva et al.4 using the same manoeuvre (TC); however, the vasoconstrictor response, although sufficient to maintain MAP, is not so important, perhaps because the patients studied by this author were not cirrhotics. Our results show an abnormal vasoconstrictor capacity in cirrhotic patients, which suggests
1. Oliver M, Miralles R, Rubie´s J, et al: J Hepatol 26:1242, 1997 2. Laffi G, Barletta G, La Villa G, et al: Gastroenterology 113:891, 1997 3. Laffi G, Lagi A, Cipriani M, et al: Hepatology 24:1063, 1996 4. Delva E, Huguet C, Camus Y, et al: Anesthesiology 65:A409, 1986 5. Thomson I: Can Anaesth Soc J 31:S31, 1984 6. Acosta F, Sansano T, Reche M, et al: Transplant Proc 31:2368, 1999 7. Acosta F, De la Morena G, Villegas M, et al: Transplant Proc 31:2369, 1999
A
LTERATIONS in the autonomic nervous systems lead to heart and circulation disorders that occur in cirrhosis.1 During orthotopic liver transplantation (OLT), the vascular exclusion of the liver in the anhepatic phase requires an important vasoconstrictor response to maintain arterial pressure. Our aim was to determine whether the characteristics of this response differ between patients with alcoholic and nonalcoholic etiology. PATIENTS AND METHODS We studied 60 cirrhotic patients undergoing OLT divided into two groups: group A (n ⫽ 38), patients diagnosed with alcoholic cirrhosis; and group B (n ⫽ 22), patients diagnosed with nonalcoholic cirrhosis. To discover beforehand the need of venovenous bypass (VVBP), we performed trial clamping (TC) of the infrahepatic vena cava and portal vein during the dissection phase. We performed a complete hemodynamic profile using a pulmonary artery catheter before (pre-TC) and 5 minutes after (post-TC) the start of TC. We indicated VVBP when the systolic arterial pressure did not exceed 100 mm Hg during TC. The following measure-
ments or calculations were made: heart rate (HR); mean arterial and pulmonary artery pressures (MAP, MPAP); central venous and pulmonary capillary wedge pressures (CVP, PCWP); cardiac index (CI); right and left ventricular stroke work indexes (RVSWI, LVSWI); and pulmonary and systemic vascular resistance indexes (PVRI, SVRI).
Statistics Student’s t and chi-square tests were used. Significance was set at P ⬍ .05.
RESULTS
We found no differences between the groups for ChildPugh grade or for indication of VVBP: six patients in group From the Liver Transplant Unit, University Hospital “V.Arrixaca,” Murcia, Spain. Address reprint requests to Dr Francisco Acosta, San Cristo´bal, 4 (3B), 30001-Murcia, Spain.
Table 1. Hemodynamic Changes With TC in Cirrhotic Patients
HR (beats/min) MAP (mm Hg) MPAP (mm Hg) CVP (mm Hg) PCWP (mm Hg) CI (L/min 䡠 m2) RVSWI (g/m 䡠 m2) LVSWI (g/m 䡠 m2) PVRI (dyn 䡠 s/cm5m2) SVRI (dyn 䡠 s/cm5m2)
Group
Pre-TC
Post-TC
Change (%)
A B A B A B A B A B A B A B A B A B A B
93.0 ⫾ 16.6 87.1 ⫾ 15.2 78.5 ⫾ 13.7 77.6 ⫾ 14.9 19.2 ⫾ 5.5 18.6 ⫾ 3.7 8.3 ⫾ 3.6 9.0 ⫾ 2.1 13.2 ⫾ 3.9 12.7 ⫾ 2.8 5.3 ⫾ 1.2 5.1 ⫾ 1.0 7.8 ⫾ 3.3 8.0 ⫾ 3.1 51.3 ⫾ 12.0 48.1 ⫾ 11.9 91.2 ⫾ 23.7 96.7 ⫾ 28.3 1150 ⫾ 308 1087 ⫾ 322
101.2 ⫾ 17.4 97.4 ⫾ 16.8† 74.3 ⫾ 12.6 72.7 ⫾ 13.8 13.8 ⫾ 4.7* 12.9 ⫾ 3.3# 5.4 ⫾ 1.9* 5.8 ⫾ 2.2# 8.9 ⫾ 1.6* 8.6 ⫾ 2.7# 2.9 ⫾ 0.9* 2.6 ⫾ 0.8* 3.2 ⫾ 1.4* 2.8 ⫾ 1.9* 26.1 ⫾ 8.4* 24.0 ⫾ 7.9* 138.6 ⫾ 49.8# 168.1 ⫾ 58.3# 1866 ⫾ 410* 1922 ⫾ 436* †
9 12 ⫺6 ⫺7 ⫺28 ⫺31 ⫺35 ⫺37 ⫺32 ⫺34 ⫺45 ⫺49 ⫺59 ⫺65 ⫺49 ⫺51 52 74 63 76
See text for abbreviations. Values expressed as mean ⫾ SD. † P ⬍ .05, #P ⬍ .01, and *P ⬍ .001 vs Pre-TC.
0041-1345/00/$–see front matter PII S0041-1345(00)01831-5
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2662
Transplantation Proceedings, 32, 2662–2663 (2000)
VASOCONSTRICTOR RESPONSE
2663
A and four in group B. All the hemodynamic variables compared were modified after TC except MAP, although we found no differences between the groups for any of them (Table 1).
altered humoral and/or reflex mechanisms,4,5 but as mentioned in previous studies,6,7 we cannot confirm an impaired myocardial contractility.
DISCUSSION
REFERENCES
An altered cardiovascular responsiveness to head-up tilting in patients with nonalcoholic cirrhosis has recently been shown.2,3 In our series the response to TC does not differ according to the etiology of the cirrhosis. We observe that the decrease in CI is similar to that found by Delva et al.4 using the same manoeuvre (TC); however, the vasoconstrictor response, although sufficient to maintain MAP, is not so important, perhaps because the patients studied by this author were not cirrhotics. Our results show an abnormal vasoconstrictor capacity in cirrhotic patients, which suggests
1. Oliver M, Miralles R, Rubie´s J, et al: J Hepatol 26:1242, 1997 2. Laffi G, Barletta G, La Villa G, et al: Gastroenterology 113:891, 1997 3. Laffi G, Lagi A, Cipriani M, et al: Hepatology 24:1063, 1996 4. Delva E, Huguet C, Camus Y, et al: Anesthesiology 65:A409, 1986 5. Thomson I: Can Anaesth Soc J 31:S31, 1984 6. Acosta F, Sansano T, Reche M, et al: Transplant Proc 31:2368, 1999 7. Acosta F, De la Morena G, Villegas M, et al: Transplant Proc 31:2369, 1999