Hepatopulmonary syndrome echocardiography and ultrasound

A schematic view of agitated saline injection test. Bubbles should not pass through the pulmonary vasculature and should be trapped in healthy subjects (1, 2, 3 ), but in patients with shunts such as patients with hepatopulmonary syndrome, they will appear in the left heart and the systemic circulation subsequently (4, 5, 6). Artwork by Soroush Seifirad, MD.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]

Overview

Both contrast-enhanced transthoracic and transesophageal echocardiography may be helpful in the diagnosis of hepatopulmonary syndrome. In fact, contrast-enhanced transthoracic echocardiography with agitated saline is the most practical method to detect pulmonary vascular dilation. It can not only diagnose the presence of shunt but also can distinguish between intracardiac and intrapulmonary shunt. Findings on an echocardiography suggestive of hepatopulmonary syndrome include the presence of agitated saline bubbles after injection in a peripheral vein in the patient’s arm. The timing of the appearance of the left-sided bubbles after injection can determine the source of the shunt. while bubbles appear in the left chambers three cardiac cycles after the appearance of the bubbles in the right heart chambers in intracardiac shunting, in intrapulmonary shunting, four to six cardiac cycles are passed before appearance of the bubbles in the right heart chambers. Transesophageal echocardiography (TTE) is also helpful in the diagnosis of hepatopulmonary syndrome. TTE can detect intrapulmonary vascular dilations with greater specificity compared to transthoracic echocardiography since the examiner can directly observe microbubbles in the pulmonary veins as they enter the left atrium. Additionally, cardiac function and pulmonary artery pressures can also be evaluated.

Echocardiography

• Transthoracic echocardiography
• Contrast-enhanced transthoracic echocardiography with agitated saline is the most practical method to detect pulmonary vascular dilation.

• The agitated saline is administered in a peripheral vein in the patient’s arm, exceed the normal pulmonary capillary diameter and should be trapped normally.
• In normal physiologic states, particles greater than 20 microns in diameter, (normal range of pulmonary capillary diameter is less than 8 to 15 microns) are trapped and filtered by the pulmonary capillary bed and do not appear in the left side of the heart and general circulation.
• However, in the presence of an intrapulmonary or intracardiac right-to-left shunt, those particles may be detected either in the left heart chambers or in the other organs such as brain or kidneys.
• Contrast-enhanced transthoracic echocardiography could distinguish between intracardiac and intrapulmonary shunt.
• The timing of the appearance of the left-sided bubbles after injection can determine the source of the shunt.

• In intracardiac shunting: three cardiac cycles after the appearance of the bubbles in the right heart chambers.
• In intrapulmonary shunting: four to six cardiac cycles after the appearance of the bubbles in the right heart chambers.

• More sensitive than technetium 99m-labeled macroaggregated albumin test
• less invasive than pulmonary angiography. and transesophageal echocardiography (TTE)

{{#ev:youtube|mmxFgZMutQg}} {{#ev:youtube|sYM1HYFpyXA}} Transesophageal echocardiography

Findings on transesophageal echocardiography suggestive of hepatopulmonary syndrome include:

• Transesophageal echocardiography (TTE) is also helpful in the diagnosis of hepatopulmonary syndrome.
• TTE can detect intrapulmonary vascular dilations with greater specificity compared to transthoracic echocardiography since the examiner can directly observe microbubbles in the pulmonary veins as they enter the left atrium.
• Additionally, cardiac function, and pulmonary artery pressures can also be evaluated.

Limitations

• More invasive compared to transthoracic echocardiography