Echocardiographic prevalence of pulmonary arterial hypertension in end-stage liver disease and its correlation with post-transplant mortality: when does the pulmonary artery catheter matter?

Abstract Background and objectives Liver transplantation (LT) is the gold standard treatment for end-stage liver disease (ESLD), but pulmonary arterial hypertension (PAH) can significantly affect post-transplant outcomes. While echocardiography provides a non-invasive screening tool for PAH, the role of invasive pulmonary artery catheterization (PAC) in these patients remains unclear. This study aimed to assess the prevalence of PAH in ESLD patients using echocardiography and explore its correlation with post-transplant mortality. Methods This retrospective cohort study, conducted at the Specialized Center for LT, included ESLD patients preparing for LT from January 2021 to December 2023. Data were collected from patient records, including echocardiographic assessments of right ventricular function, pulmonary function tests, chest imaging, and laboratory evaluations. In-hospital and 1-year mortality rates were also recorded. Results Seventy-five ESLD patients undergoing LT had a mean age of 51.18 ± 11.83 years, with 68% male predominance. Chronic viral hepatitis, cryptogenic cirrhosis, and non-alcoholic steatohepatitis were the primary causes of liver failure, and hepatocellular carcinoma was present in 18.67%. Comorbidities were infrequent, with diabetes in 24%. Echocardiographic assessment revealed moderate to severe PAH in 53.33% of patients, with 17.33% exhibiting explicit PAH based on pulmonary artery acceleration time (PAAT) and right ventricular systolic pressure (RVSP). A significant negative correlation was found between PAAT and RVSP ( r = − 0.52, p < 0.001). Mortality rate was 24%, with half occurring within 30 days and the other half within a year. PAH correlated with increased overall and short-term mortality. Predictors of mortality included elevated creatinine, chronic kidney disease, reduced AST levels, and prolonged prothrombin time. Shorter PAAT was a significant predictor of mortality, with a PAAT < 94 ms showing high specificity but low sensitivity, while a PAAT < 103.5 ms had high sensitivity but lower specificity. Conclusion A significant prevalence of PAH was observed in patients with ESLD, with a notable correlation between PAH and both overall and short-term mortality following LT. Given the high mortality risk associated with PAH, especially in patients with a PAAT < 94 ms, the study advocates for further hemodynamic assessment using pulmonary artery catheterization in this group before transplantation. This approach may enhance risk stratification, enabling more targeted interventions that could ultimately improve post-transplant outcomes and survival rates.