Utility of dobutamine stress echocardiography as part of the pre-liver transplant evaluation: An evaluation of its efficacy

Background Dobutamine stress echocardiography (DSE) is commonly used to risk stratify patients in the cardiac evaluation prior to orthotopic liver transplantation (OLT). Data remain limited regarding the accuracy to predict obstructive coronary artery disease (CAD) using this approach. Hypothesis We hypothesize that DSE may have limitations in the investigation of underlying CAD in patients with end-stage liver disease. Methods A retrospective chart review of all patients who underwent OLT at Mayo Clinic in Florida between 1998 and 2010 was performed. Sixty-six underwent invasive coronary angiography (ICA) within 1 year of DSE and were included in our study. Based on DSE results, patients were stratified into 1 of 3 groups: nonischemic, ischemic, and indeterminate. The relationship between DSE, ICA, and death from all cause and cardiac-related cause with a minimum 3-year follow-up period were analyzed. Results A total of 66 patients were included in our cohort. There was no difference in age, gender, severity of liver disease, and echocardiographic findings among the groups. Forty-three percent of patients (n=12) with an abnormal result on DSE were found to have moderate or severe obstructive CAD on cardiac catheterization, whereas 49% of patients (n=17) with a normal finding on DSE had moderate or severe CAD. Of 5 patients who died from a documented cardiac etiology, 3 had normal stress test results, 1 had abnormal findings, and 1 had an indeterminate DSE result. When compared with ICA, our study demonstrated that DSE has a sensitivity of 41.4% (95% confidence interval [CI]: 0.24-0.61), specificity of 47.1% (95% CI: 0.30-0.65), positive predictive value of 40.0% (95% CI: 0.23-0.59), and negative predictive value of 48.0% (95% CI: 0.31-0.66) in identification of underlying CAD. Conclusions Although widely used, DSE may not always accurately reflect the severity of obstructive CAD in patients undergoing OLT.