Enhancing Liver Transplant Success: Echocardiography’s Role in Assessing Pulmonary Hypertension

Pulmonary hypertension poses a significant challenge for liver transplant candidates, often complicating the eligibility and success rates of potential transplant recipients. At the forefront of addressing this challenge is the echocardiographic assessment, a vital tool for evaluating pulmonary hypertension within this patient demographic. Teams are using echocardiography as the first screen and verifying risks with right heart catheterization before listing.

In candidates with suspected portopulmonary hypertension, echocardiography initiates evaluation, while hemodynamic confirmation by right heart catheterization determines candidacy.

One of the key mechanisms at play involves the echocardiographic assessment’s ability to estimate pulmonary artery pressures for initial screening, a factor in gauging transplant eligibility. As a screening tool, echocardiography offers non-invasive estimates; however, confirmation of pulmonary hemodynamics and transplant eligibility relies on right heart catheterization.

Transitioning from these insights, the notable preference for echocardiography over right heart catheterization stems from its non-invasive nature, making it an effective screening tool. Major society guidelines concur: echocardiography is first-line for screening, whereas right heart catheterization is required to confirm pulmonary hypertension and assess mPAP and PVR before listing for transplant.

These studies support echocardiography as a low-risk, accessible first step in pre-transplant evaluation; however, they do not obviate the need for right heart catheterization when pulmonary hypertension is suspected, as emphasized in a recent study.

Despite these advances, managing pulmonary hypertension in this fragile cohort remains a formidable clinical challenge. Variations in patient hemodynamics often require sophisticated interpretations and tailored interventions, vital in navigating the complexities of pre-transplant evaluations. For those patients experiencing these dynamics, understanding these nuances can mean the difference between candidacy and ineligibility.

In practice, centers follow a workflow that begins with transthoracic echocardiography to estimate right ventricular systolic pressure and screen for signs of right-sided strain. When findings raise concern for pulmonary hypertension, right heart catheterization measures mean pulmonary artery pressure and pulmonary vascular resistance, clarifying severity and perioperative risk. These data then guide therapy and timing decisions before listing.

Optimization before transplant commonly includes diuretics for volume control, oxygen for hypoxemia, and targeted pulmonary vasodilator therapy in select patients. The goal is to improve hemodynamics to thresholds considered acceptable for surgery while avoiding adverse effects on systemic blood pressure or portal flow. Close coordination among hepatology, cardiology, anesthesia, and pulmonary hypertension specialists is essential.

Such insights are informing, rather than overturning, how clinicians approach transplant viability. However, echocardiographic estimates can be limited by suboptimal TR signals and cirrhosis-related hemodynamics; multidisciplinary review and catheter-based confirmation remain central to decision-making.

For patients experiencing the unpredictability of pulmonary hypertension and liver disease, echocardiography not only democratizes access to vital diagnostic insights but also reduces reliance on invasive procedures for initial screening while reserving right heart catheterization for cases requiring confirmation and hemodynamic profiling.

For many programs, clear documentation of hemodynamic status helps align expectations and plan perioperative management, including vasodilator continuation, volume strategies, and monitoring needs. This shared, stepwise approach reduces delays and focuses invasive testing where it will change management.

When successfully optimized, some candidates proceed to transplant with improved risk profiles, while others may defer listing until hemodynamics are safer. Throughout, the combination of non-invasive screening and invasive confirmation provides a balanced pathway that prioritizes safety and clarity in decision-making.

Key Takeaways:

• Echocardiography is used as a first-line screen; right heart catheterization confirms pulmonary hypertension and quantifies mPAP and PVR prior to listing.
• Screening by echo is low risk and accessible, but estimates can be limited by TR signal quality and cirrhosis-related hemodynamics, necessitating multidisciplinary review.
• Care pathways typically follow a stepwise workflow: screening → catheter-based confirmation → hemodynamic optimization → transplant planning.
• Pre-transplant optimization aims to improve risk while preserving systemic and portal hemodynamics; invasive testing is reserved for when results will change management.