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World J Hepatol. Mar 27, 2015; 7(3): 507-520
Published online Mar 27, 2015. doi: 10.4254/wjh.v7.i3.507
Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients
Suehana Rahman, Susan V Mallett
Suehana Rahman, Susan V Mallett, Department of Anaesthesia, Royal Free London NHS Trust, London NW3 2QG, United Kingdom
Author contributions: Rahman S and Mallett SV contributed equally to this work.
Conflict-of-interest: The authors of this manuscript have no conflicts of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Suehana Rahman, MBBS, FRCA, Clinical Research Fellow, Department of Anaesthesia, Royal Free London NHS Trust, Pond Street, London NW3 2QG, United Kingdom. suehana.rahman@nhs.net
Telephone: +44-207-7940500 Fax: +44-207-8302245
Received: September 11, 2014
Peer-review started: September 11, 2014
First decision: November 3, 2014
Revised: December 1, 2014
Accepted: December 16, 2014
Article in press: December 16, 2014
Published online: March 27, 2015
Abstract

Cirrhotic cardiomyopathy is a disease that has only recently been recognised as a definitive clinical entity. In the setting of liver cirrhosis, it is characterized by a blunted inotropic and chronotropic response to stress, impaired diastolic relaxation of the myocardium and prolongation of the QT interval in the absence of other known cardiac disease. A key pathological feature is the persistent over-activation of the sympathetic nervous system in cirrhosis, which leads to down-regulation and dysfunction of the β-adrenergic receptor. Diagnosis can be made using a combination of echocardiography (resting and stress), tissue Doppler imaging, cardiac magnetic resonance imaging, 12-lead electrocardiogram and measurement of biomarkers. There are significant implications of cirrhotic cardiomyopathy in a number of clinical situations in which there is an increased physiological demand, which can lead to acute cardiac decompensation and heart failure. Prior to transplantation there is an increased risk of hepatorenal syndrome, cardiac failure following transjugular intrahepatic portosystemic shunt insertion and increased risk of arrhythmias during acute gastrointestinal bleeding. Liver transplantation presents the greatest physiological challenge with a further risk of acute cardiac decompensation. Peri-operative management should involve appropriate choice of graft and minimization of large fluctuations in preload and afterload. The avoidance of cardiac failure during this period has important prognostic implications, as there is evidence to suggest a long-term resolution of the abnormalities in cirrhotic cardiomyopathy.

Keywords: Cirrhotic cardiomyopathy, Liver transplantation, Diastolic dysfunction, Electrophysiological abnormalities, Perioperative care

Core tip: Cirrhotic cardiomyopathy is characterised by a blunted inotropic and chronotropic response to stress, impaired diastolic relaxation and prolongation of the QT interval. It is only recently that it has been recognised as a definitive clinical entity, and yet it has significant implications in a number of clinical situations in which there is increased physiological demand, which can lead to acute cardiac decompensation and heart failure. Liver transplantation is one such situation, and in this review we discuss criteria for diagnosis, possible methods to limit further deterioration and the perioperative management of these patients.