The Clinical Role and Impact of Dobutamine Stress Echocardiography in Liver Transplantation

PURPOSE: Cardiovascular (CV) events remain a major source of morbidity and mortality following liver transplantation (LT). Dobutamine stress echocardiography (DSE) is commonly used for pre-transplant risk stratification, though its clinical utility in this setting remains uncertain. We evaluated post-transplant outcomes associated with abnormal DSE findings to explore its role in CV risk assessment. METHODS: Adult LT candidates who underwent DSE at a single center were included. DSE results were categorized as positive, negative, or inadequate. The primary outcome was postoperative cardiac events; secondary outcomes included mortality and transplant delays. Analyses included Mann-Whitney U and Fisher's exact tests, ROC analysis, logistic regression, and random survival forest (RSF) modeling. RESULTS: Of 981 evaluated candidates, 644 (66%) underwent DSE. Postoperative cardiac events occurred in 25 patients (4%), none had a positive DSE. Of six patients with positive DSE, one had obstructive coronary disease on subsequent testing. Inadequate DSE (mostly failure to reach target heart rate or hemodynamic intolerance) occurred in 113 patients (18%); 30% underwent further evaluation, with a median transplant delay of 25 (IQR 2.5-43) days. Pooling positive and inadequate DSE yielded an AUC of 0.64 and odds ratio of 2.25 (p < 0.01) for association with postoperative cardiac events. RSF modeling identified five hemodynamic features during DSE as top predictors. CONCLUSION: DSE may have limited utility when interpreted within a binary positive/negative framework in LT candidates. Inadequate DSE may identify higher-risk patients but may lead to increased downstream testing and transplant delays. Physiological responses during stress testing may provide complementary information for risk assessment and warrant further investigation.