**Introduction/Hypothesis:**
The 2022 scientific statement from the American College of Cardiology/American Heart Association (ACC/AHA) and the 2015 European Association for the Study of the Liver (EASL) clinical practice guidelines recommend screening transthoracic echocardiography (TTE) for all patients being evaluated for liver transplantation. Despite this recommendation, there is a dearth of evidence regarding the association between various echocardiographic parameters and outcomes post transplantation. Our study aims to investigate the association between various echocardiographic findings, mortality, and postoperative systolic dysfunction in patients receiving liver transplants.

**Methods**
This was a single center retrospective cohort study. We analyzed all patients who underwent liver transplantation from 1/2010 until 12/2019. Patients were excluded if there was no preoperative TTE. The echocardiographic findings of interest in this study were left ventricular ejection fraction (LVEF), right ventricular systolic pressure (RVSP), diastolic dysfunction, and valvular heart disease. The primary outcome of our study was all-cause mortality. Secondary outcome in our study was new onset systolic dysfunction. Systolic dysfunction was defined as an LVEF of < 50%. Left ventricular ejection fraction was analyzed both as a continuous variable and also broken down into 3 sections (LVEF < 50%, 51 - 65%, and > 65%). The same was done for RVSP. The stratification for RVSP was < 25mmHg, and > 25mmHg. Diastolic dysfunction was generated as a factor variable with “no diastolic dysfunction” being the reference category. The other two categories were either “present” or “indeterminate.” The grading of the dysfunction was not done during this study. Valvular heart disease (VHD) was also analyzed as a factor variable and stratified as either present or not present. The VHDs of interest were mitral regurgitation, tricuspid regurgitation, aortic stenosis, and aortic regurgitation. Other categories of VHDs did not occur in sufficient numbers to draw meaningful conclusions. VHD was only included in this study if it was at least moderate in severity by echocardiogram. The data was analyzed using univariate logistic regression.

**Results**
There were 1449 patients included in our study, of which 1361 (94.06%) had an echocardiogram within 1 year of transplantation. The average LVEF and RVSP of all included patients were 66% and 31 mmHg respectively. 9  patients (0.66%) had an LVEF < 50%, 684 (50.18%) had an EF between 50 - 65%, and 667 (49.94%) had an EF > 65%. 185 patients (13.57%) had an RVSP of < 25 mmHg, 521 (38.22%) had an RVSP 25 - 40 mmHg, and 90 (3.30%) had an RVSP of > 40 mmHg.  273 (20%) had diastolic dysfunction with at least Grade 1 severity. 258 (18.93%) had indeterminate diastolic function. In regards to VHD, 60 (4.40%) had mitral regurgitation (MR), 44 (3.23%) had tricuspid regurgitation (TR), 10 (0.73%) had aortic regurgitation (AR), and 14 (1.03%) had aortic stenosis (AS). At the end of the study 291 (20.08%) of patients had died, and 76 (5.24%) of patients had new onset systolic dysfunction.
Factors found to be associated with an increased mortality were the presence of diastolic dysfunction (OR 1.53; 95% CI 1.10 - 2.11), and LVEF > 65% (OR 1.29; 95% CI 0.99 - 1.68). An LVEF between 50 - 65% was associated with decreased risk for mortality (OR: 0.77; 95% CI 0.59 - 1). An LVEF > 65% prior to liver transplantation was found to be associated with decreased odds of systolic dysfunction after surgery (OR 0.59; 95% CI 0.35 - 0.96).

**Conclusion**
Echocardiography is recommended prior to liver transplantation but the parameters associated with a worse prognosis post transplant are unclear. Our study demonstrates that the presence of diastolic dysfunction and an LVEF > 65% were both associated with an increased risk for mortality. Neither right ventricular systolic pressure nor valvular heart disease were associated with mortality or new onset systolic dysfunction.



Echocardiographic Factors Associated with Mortality in Liver Transplantation