In Reference to “Tricuspid Regurgitation on Echocardiography May Not Be a Predictor of Patient Survival After Liver Transplantation”

To the Editor: We appreciate the commentary by Leithead et al (1Leithead JA Kandiah K Steed H Gunson BK Steeds RP Ferguson JW Tricuspid regurgitation on echocardiography may not be a predictor of patient survival after liver transplantation.Am J Transplant. 2014; 14: 2193-2194Abstract Full Text Full Text PDF Scopus (8) Google Scholar) in response to our study evaluating the role of pretransplant echocardiography in predicting outcomes following liver transplantation (LT). In our retrospective study of 216 patients who underwent pre-LT echocardiography, we found the presence of ≥ mild tricuspid regurgitation (TR) to be predictive of patient and graft survival (2Kia L Shah SJ Wang E et al.Role of pretransplant echocardiographic evaluation in predicting outcomes following liver transplantation.Am J Transplant. 2013; 13: 2395-2401Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar). Leithead et al (1Leithead JA Kandiah K Steed H Gunson BK Steeds RP Ferguson JW Tricuspid regurgitation on echocardiography may not be a predictor of patient survival after liver transplantation.Am J Transplant. 2014; 14: 2193-2194Abstract Full Text Full Text PDF Scopus (8) Google Scholar) performed a somewhat similar study at their institution, and their data do not demonstrate an association, and they suggest that our findings should be interpreted with caution. We acknowledge that their findings are in fact very interesting, although it is difficult to directly compare our studies and patient populations. First, the authors do not specify in their methods how the echocardiographic data were extracted. There can be significant interobserver variability in grading TR, which was not a consideration in our study as all echocardiograms were read by a single, trained, blinded reader using predefined, established criteria (3Rudski LG Lai WW Afilalo J et al.Guidelines for the echocardiographic assessment of the right heart in adults: A report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.J Am Soc Echocardiogr. 2010; 23: 685-713Abstract Full Text Full Text PDF PubMed Scopus (4863) Google Scholar,4Zoghbi WA Enriquez-Sarano M Foster E et al.Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.J Am Soc Echocardiogr. 2003; 16: 777-802Abstract Full Text Full Text PDF PubMed Scopus (3389) Google Scholar). It is unclear whether a similar protocol was used in their data set. Second, the authors state that they excluded patients with pulmonary hypertension, but they do not define the parameters by which they were excluded from analysis. Our study excluded only patients with moderate-to-severe portopulmonary hypertension who were deemed not to be transplant candidates. Last, as the authors point out, their patient population had an average calculated Model for End-Stage Liver Disease (MELD) score that was much lower than ours (15 vs. 25), suggesting that our population was sicker with less reserve and more susceptible to subtle hemodynamic changes such as mild TR. In summary, we agree that TR in healthier populations (lower MELD, no pulmonary hypertension) may have less impact on patient and graft survival, but as liver failure advances and transplantation becomes more imminent in our region and others in the United States, our data suggest a greater impact of TR. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

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