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Background  The assessment of cardiac risk in contemporary liver transplantation ( LT ) has required more sensitive testing for the detection of occult coronary artery disease as well as microvascular and functional cardiac abnormalities. Because dobutamine stress perfusion echocardiography provides an assessment of both regional systolic and diastolic function as well as microvascular perfusion ( MVP ), we sought to examine its incremental value in this setting.    Methods and Results  We evaluated the predictive value of dobutamine stress perfusion echocardiography in 296 adult patients with end‐stage liver disease and preserved systolic function who underwent  LT  between 2008 and 2014. The primary outcome was cardiovascular death, nonfatal myocardial infarction, and/or sustained ventricular arrhythmias following  LT . The main causes of liver failure were hepatitis C (25%) and nonalcoholic fatty liver disease (13%). Abnormal  MVP  during stress was observed in 18 patients (6%), whereas diastolic dysfunction was present in 109 patients (94 grade 1, 15 grade 2). Half of the patients (7 of 14) referred for angiography with abnormal  MVP  had significant epicardial disease by angiography, and these patients were revascularized prior to  LT . Despite these interventions, the primary outcome still occurred in 9 patients (3%). Patients with abnormal  MVP  during dobutamine stress perfusion echocardiography had a 7‐fold higher risk of a cardiovascular event following  LT . Cox proportional hazards modeling examining clinical variables, left ventricular ejection fraction, diastolic function, and stress‐induced wall motion abnormalities or  MVP  defects demonstrated that abnormal  MVP  was the only independent predictor of the primary outcome ( P =0.004; hazard ratio 7.7).    Conclusions  Stress  MVP  assessments are highly predictive of cardiovascular outcome in current LT candidates.

Predictive Value of Dobutamine Stress Perfusion Echocardiography in Contemporary End‐Stage Liver Disease