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Lupu D, Nedelcu L, Țînț D. The Interplay between Severe Cirrhosis and Heart: A Focus on Diastolic Dysfunction. J Clin Med 2024; 13:5442. [PMID: 39336928 PMCID: PMC11432364 DOI: 10.3390/jcm13185442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/06/2024] [Accepted: 09/10/2024] [Indexed: 09/30/2024] Open
Abstract
Background/Objectives: Cardiovascular involvement in severe cirrhosis presents diagnostic challenges and carries significant prognostic implications. This study aims to evaluate the relationship between liver disease severity and portal hypertension with the burden of diastolic dysfunction. Methods: We prospectively enrolled patients with hepatic cirrhosis, classified according to the Child-Pugh criteria. Of the 102 patients included, 65 were classified as Group A (non-severe cirrhosis: Child-Pugh Classes A and B) and 37 as Group B (severe cirrhosis: Child-Pugh Class C). Portal vein and spleen diameters were assessed using abdominal ultrasound. All patients underwent echocardiographic evaluation. LV systolic function was assessed by measuring ejection fraction, while diastolic function was evaluated using three parameters: E/Em ratio, E/Vp ratio, and indexed left atrial volume. Results: We observed a significantly greater burden of diastolic dysfunction in Group B compared to Group A. Specifically, the E/Vp ratio was 2.2 ± 0.4 in Group B versus 1.9 ± 0.3 in Group A (p < 0.001); the indexed LA volume was 34.5 ± 3.2 mL/m2 in Group B versus 30.1 ± 2.9 mL/m2 in Group A (p < 0.001); and the E/Em ratio was 17.0 ± 3.0 in Group B versus 11.5 ± 2.8 in Group A (p < 0.001). Additionally, the mean diameters of the portal vein and spleen were larger in Group B, with measurements of 14.3 ± 2.1 mm versus 11.5 ± 1.6 mm for the portal vein and 15.0 ± 1.2 mm versus 11.7 ± 1.5 mm for the spleen (p < 0.001), which correlated with the extent of diastolic dysfunction. Conclusions: Diastolic dysfunction was prevalent in 55% of patients with liver cirrhosis. The burden of diastolic dysfunction was higher in patients with severe hepatic cirrhosis compared to those with milder forms, and it correlated with the severity of portal hypertension, as assessed by measuring portal vein diameter and spleen diameter.
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Affiliation(s)
- Dragoș Lupu
- Department of Fundamental, Prophylactic, and Clinical Disciplines, Transilvania University of Brasov, 500036 Brașov, Romania
- ICCO Clinics Brasov, Transilvania University of Brasov, 500059 Brașov, Romania
| | - Laurențiu Nedelcu
- Department of Fundamental, Prophylactic, and Clinical Disciplines, Transilvania University of Brasov, 500036 Brașov, Romania
| | - Diana Țînț
- ICCO Clinics Brasov, Transilvania University of Brasov, 500059 Brașov, Romania
- Department of Medical and Surgical Specialties, Transilvania University of Brasov, 500036 Brașov, Romania
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2
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Gananandan K, Wiese S, Møller S, Mookerjee RP. Cardiac dysfunction in patients with cirrhosis and acute decompensation. Liver Int 2024; 44:1832-1841. [PMID: 38712826 DOI: 10.1111/liv.15896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
The prevalence of cirrhotic cardiomyopathy (CCM) has been reported as high as 60%-70% in patients with liver cirrhosis and is associated with various negative outcomes. There has been a growing understanding of CCM over recent years. Indeed, the development of imaging techniques has enabled new diagnostic criteria to be proposed by the Cirrhotic Cardiomyopathy Consortium. However, important unanswered questions remain over pathophysiological mechanisms, optimal diagnostic modalities and potential treatment options. While there has been an increasing volume of literature evaluating CCM, there is a lack of clarity on its implications in acute decompensation, acute-on-chronic liver failure and following interventions such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. This review aims to summarise the literature in these challenging domains and suggest where future research should focus. We conclude that systemic inflammation and structural myocardial changes are likely to be crucial in the pathophysiology of the disease, but the relative contribution of different components remains elusive. Furthermore, future studies need to use standardised diagnostic criteria for CCM as well as incorporate newer imaging techniques assessing both myocardial structure and function. Finally, while specific treatments are currently lacking, therapeutics targeting systemic inflammation, microbial dysbiosis and bacterial translocation are promising targets and warrant further research.
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Affiliation(s)
- Kohilan Gananandan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Signe Wiese
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Gastroenterology Unit, Medical Division, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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3
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Kalambokis G, Christaki M, Tsiakas I, Despotis G, Lakkas L, Tsiouris S, Xourgia X, Markopoulos GS, Dova L, Milionis H. Association of left ventricular diastolic dysfunction with inflammatory activity, renal dysfunction, and liver-related mortality in patients with cirrhosis and ascites. Eur J Gastroenterol Hepatol 2024; 36:775-783. [PMID: 38526935 DOI: 10.1097/meg.0000000000002762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Left ventricular diastolic dysfunction (LVDD) is the predominant cardiac abnormality in cirrhosis. We investigated the association of LVDD with systemic inflammation and its impact on renal function, occurrence of hepatorenal syndrome (HRS) and survival in patients with cirrhosis and ascites. We prospectively enrolled 215 patients with cirrhosis and ascites. We evaluated the diagnosis and grading of LVDD by Doppler echocardiography, inflammatory markers, systemic hemodynamics, vasoactive factors, radioisotope-assessed renal function and blood flow, HRS development and liver-related mortality. LVDD was diagnosed in 142 (66%) patients [grade 2/3: n = 61 (43%)]. Serum lipopolysaccharide-binding protein (LBP), plasma renin activity (PRA) and glomerular filtration rate (GFR) were independently associated with the presence of grade 2/3 LVDD and the severity of diastolic dysfunction. Serum tumor necrosis factor-α, cardiac output and plasma noradrenaline were also independently associated with the presence of grade 2/3 LVDD. The diastolic function marker E / e ' was strongly correlated with serum LBP ( r = 0.731; P < 0.001), PRA ( r = 0.714; P < 0.001) and GFR ( r = -0.609; P < 0.001) among patients with LVDD. The 5-year risk of HRS development and death was significantly higher in patients with grade 2/3 LVDD compared to those with grade 1 (35.5 vs. 14.4%; P = 0.01 and 53.3 vs. 28.2%; P = 0.03, respectively). The occurrence and severity of LVDD in patients with cirrhosis and ascites is closely related to inflammatory activity. Advanced LVDD is associated with baseline circulatory and renal dysfunction, favoring HRS development, and increased mortality.
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Affiliation(s)
| | | | | | | | | | | | | | - Georgios S Markopoulos
- Hematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, Medical School, University of Ioannina, Ioannina, Greece
| | - Lefkothea Dova
- Hematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, Medical School, University of Ioannina, Ioannina, Greece
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Dimitroglou Y, Aggeli C, Alexopoulou A, Tsartsalis D, Patsourakos D, Koukos M, Tousoulis D, Tsioufis K. The Contemporary Role of Speckle Tracking Echocardiography in Cirrhotic Cardiomyopathy. Life (Basel) 2024; 14:179. [PMID: 38398688 PMCID: PMC10890501 DOI: 10.3390/life14020179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Cirrhotic cardiomyopathy (CCM) is characterized by elevated cardiac output at rest, an inability to further increase contractility under stress, and diastolic dysfunction. The diagnosis of CCM is crucial as it can lead to complications during liver transplantation. However, its recognition poses challenges with conventional echocardiography techniques. Speckle tracking echocardiography (STE), particularly global longitudinal strain (GLS), is a novel index that enhances the diagnostic efficacy of echocardiography for both ischemic and non-ischemic cardiomyopathies. GLS proves more sensitive in identifying early systolic dysfunction and is also influenced by advanced diastolic dysfunction. Consequently, there is an expanding scope for GLS utilization in cirrhotic cases, with newly updated diagnostic criteria for CCM incorporating GLS. Specifically, systolic dysfunction is now defined as either a left ventricular ejection fraction below 50% or an absolute GLS below 18%. However, conflicting data on GLS alterations in liver cirrhosis patients persist, as many individuals with advanced disease and a poor prognosis exhibit a hyperdynamic state with preserved or increased GLS. Consequently, the presence of CCM, according to the updated criteria, does not exhibit a significant association-in the majority of studies-with the severity of liver disease and prognosis. Furthermore, information on other indices measured with STE, such as left atrial and right ventricular strain, is promising but currently limited. This review aims to offer a critical assessment of the existing evidence concerning the application of STE in patients with liver cirrhosis.
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Affiliation(s)
- Yannis Dimitroglou
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
| | - Constantina Aggeli
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
| | - Alexandra Alexopoulou
- Second Department of Medicine & Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece;
| | - Dimitrios Tsartsalis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
| | - Dimitrios Patsourakos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
| | - Markos Koukos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
| | - Dimitris Tousoulis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (C.A.); (D.T.); (D.P.); (M.K.); (K.T.)
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Dimitroglou Y, Tsartsalis D, Vasilieva L, Patsourakos D, Kalompatsou A, Alexopoulou A, Tousoulis D, Tsioufis K, Aggeli C. HFA-PEFF score as an independent predictor of 2-year mortality in liver cirrhosis patients. Eur J Gastroenterol Hepatol 2023; 35:204-211. [PMID: 36574311 DOI: 10.1097/meg.0000000000002472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Cardiovascular complications of liver cirrhosis include high cardiac output heart failure with reduced afterload and diastolic dysfunction. Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology (HFA-PEFF) (values 0-6) is a diagnostic tool for heart failure. It is a cluster of echocardiographic and biochemical parameters. The purpose of this prospective study was to assess if HFA-PEFF score is associated with the severity of liver disease and to determine its prognostic significance in patients with cirrhosis. METHODS Patients with cirrhosis without an acute event were enrolled. A comprehensive echocardiography study was conducted, brain natriuretic peptide and N-terminal-pro-B-type Natriuretic Peptide levels were measured and HFA-PEFF score was calculated. All patients were prospectively followed up after enrollment. The study end-point was defined as the composite of all-cause death. RESULTS Seventy-two consecutive patients [median age 59 years (inter-quartile range: 52-65), 72.2% males, Model for End-stage Liver Disease (MELD) 12.9 (8.5-16.3)] were included. The 52.8% had a high HFA-PEFF score (5 or 6) and the 47.2% intermediate/low score (0-4). HFA-PEFF score was correlated with MELD score (rho = 0.566, P < 0.001), but not with age, SBP and heart rate. The median follow-up was 24.2 (9.5-38.8) months. The 1- and 2-year cumulative mortality was higher in patients with high HFA-PEFF compared to those with intermediate/low (log-rank P < 0.001 for both). The predicted 2-year probability of survival in high vs intermediate/low HFA-PEFF was found to be a prognostic factor of death even when adjusted for age, gender and MELD score [hazard ratio = 3.539 (1.134-11.046), P = 0.029]. CONCLUSION HFA-PEFF score is high among patients with liver cirrhosis, especially those with advanced liver disease. HFA-PEFF score is associated with survival even when adjusting for cirrhosis severity.
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Affiliation(s)
| | | | - Larisa Vasilieva
- Second Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
| | | | | | - Alexandra Alexopoulou
- Second Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Hippokration General Hospital, Athens, Greece
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Ozersari S, Ünal B, Kemal Çabuk A, Eren Hazir K, Çağri Şimşek E, Ekmekci C, Küçükukur M, Betül Paköz Z, Günay S, Sari C. The prognostic value of P-wave dispersion and left atrial functions assessed with three-dimensional echocardiography in patients with cirrhosis. Eur J Gastroenterol Hepatol 2021; 33:1441-1450. [PMID: 33741802 DOI: 10.1097/meg.0000000000002129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cirrhotic cardiomyopathy (CCM) is a well-known entity. The aim of this study was to compare left atrial three-dimensional (3D) volume and P-wave dispersion (PWd) in patients with cirrhosis and a healthy population. The secondary purpose was to assess the left phasic volumes and reservoir functions with 3D echocardiography for the prediction of an increased risk of poor outcomes in patients with cirrhosis. METHODS The study included 50 patients with cirrhosis and 43 healthy control subjects without atrial fibrillation. All patients were assessed with two-dimensional (2D), 3D, and tissue Doppler transthoracic echocardiography. The PWd was calculated using a 12-lead surface electrocardiogram (ECG). Cirrhotic patients were followed up for 2.5 years for the evaluation of poor outcomes and the development of atrial fibrillation. RESULTS Patients with cirrhosis were observed to have significantly higher left atrial phasic volumes such as minimal left atrial volume (3D-LAVmin, P = 0.004) and indexed LAVmin (3D-LAVImin, P = 0.0001), and significantly decreased left atrial reservoir functions such as left atrial emptying volume (3D-LAEV, P = 0,001), left atrial ejection fraction (3D-LAEF, P = 0,001) on 3D echocardiography. PWd was determined to be significantly longer in the cirrhotic group compared with the control group (P = 0.003). In the 2.5-year follow-up period, poor outcomes occurred in 34 patients (22 patients died, six patients had liver transplantation, six patients developed atrial fibrillation/AHRE episodes). In Cox regression analysis, the MELD score (HR, 1.16 (1.06-1.26), P = 0.001) and 3D-LAVImin (HR, 0.95 (0.86-1.00), P = 0.040) were significantly associated with all-cause mortality. Cirrhotic patients with LAVImin of >15 ml/m2 were seen to have poor survival (long rank P = 0.033). CONCLUSION The results of this study showed that patients with cirrhosis had higher left atrial volume, longer PWd and worse diastolic functions compared with the control group. Higher disease severity scores were associated with left atrial function and volume. In addition, left atrial volume measured with 3DE was a strong predictor of future adverse events, and minimal left atrial volumes had a higher prognostic value than any other left atrial function indices.
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Affiliation(s)
| | - Bariş Ünal
- Cardiology, Tepecik Education and Research Hospital, İzmir, Turkey
| | - Ali Kemal Çabuk
- Cardiology, Tepecik Education and Research Hospital, İzmir, Turkey
| | | | | | - Cenk Ekmekci
- Cardiology, Tepecik Education and Research Hospital, İzmir, Turkey
| | - Murat Küçükukur
- Cardiology, Tepecik Education and Research Hospital, İzmir, Turkey
| | | | | | - Cenk Sari
- Cardiology, Tepecik Education and Research Hospital, İzmir, Turkey
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Behera MK, Narayan J, Sahu MK, Behera SK, Singh A, Mishra D, Agarwal S, Uthansingh K. Factors Predicting Cardiac Dysfunction in Patients with Liver Cirrhosis. Middle East J Dig Dis 2021; 13:216-222. [PMID: 36606224 PMCID: PMC9489459 DOI: 10.34172/mejdd.2021.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/19/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Left ventricular diastolic dysfunction (LVDD) is the earliest cardiac dysfunction noted in patients with liver cirrhosis, which increases the morbidity and mortality in such patients. There are sparse studies from India evaluating the predictive factors of LVDD in patients with cirrhosis. Hence we undertook this prospective study with an aim to evaluate the factors predicting the development of LVDD in liver cirrhosis. METHODS 104 patients with cirrhosis were enrolled in this prospective study. A detailed cardiac evaluation was done by 2 D echocardiography with tissue Doppler imaging by an experienced senior cardiologist. The severity of liver disease was defined by Model For End-Stage Liver Disease (MELD) and Child-Pugh score. RESULTS The prevalence of LVDD was 46% in our study. Multivariate logistic regression analysis revealed that serum albumin, MELD score, and presence of ascites (OR = 0.1, 95%CI 0.03-0.3, p < 0.001; Or = 1.12, 95%CI 1.03-1.22, p < 0.001; OR = 4.19, 95%CI 1.38-12.65, p < 0.01, respectively) were independent predictors of LVDD in patients with cirrhosis. Diastolic dysfunction was unrelated to age, sex, and etiology of cirrhosis. The patients with cirrhosis and LVDD had significantly higher child Pugh score, MELD score, and lower serum albumin than patients without LVDD. The echocardiographic parameters like E/e' ratio, Deceleration time (DT), and Left atrial volume index (LAVI) were significantly different in cirrhotic patients with higher MELD and child Pugh score than lower. CONCLUSION The present study showed a significant correlation of diastolic dysfunction with the severity of the liver disease. Low serum albumin, high MELD score, and presence of ascites significantly predict the development of LVDD in patients with cirrhosis.
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Affiliation(s)
- Manas Kumar Behera
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
| | - Jimmy Narayan
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
| | - Manoj Kumar Sahu
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
| | - Suresh Kumar Behera
- Department of Cardiology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
| | - Ayaskanta Singh
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
| | - Debakanta Mishra
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
,Corresponding Author: Debakanta Mishra, MD, DM Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003 Tel: + 91 9861412824 Fax: + 91 6742386333
| | - Shobhit Agarwal
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
| | - Kanishka Uthansingh
- Department of Gastroenterology, Institute of Medical Science & SUM Hospital, Siksha O Ansusandhan University, Bhubaneswar, Odisha, India, Pin 751003
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Shahvaran SA, Menyhárt O, Csedrik L, Patai ÁV. Diagnosis and Prevalence of Cirrhotic Cardiomyopathy: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2021; 46:100821. [PMID: 34016482 DOI: 10.1016/j.cpcardiol.2021.100821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 01/26/2023]
Abstract
The proposed diagnostic criteria for cirrhotic cardiomyopathy (CCM), defines it as documented echocardiographic findings of systolic or diastolic dysfunction (using conventional 2D echocardiogram), with or without electrophysiological abnormalities or elevated biomarkers in cirrhotic patients. In comparison to 2D echocardiogram, tissue Doppler imaging (TDI) has better sensitivity and specificity, when evaluating for cardiac dysfunction. This meta-analysis of 12 selected cohort studies attempted to estimate the pooled prevalence of CCM using either conventional echocardiography or TDI. Using the 2005 criteria, the pooled prevalence of CCM is 61% (P = 0.106). When TDI is used, the prevalence of CCM is at 45% (P = 0.088). Analyzing data of 615 cirrhotic patients, this study estimates the mean population-specific echocardiographic values of cirrhotic patients, including left ventricle ejection fraction (63.52%), deceleration time (229.04 ms), isovolumetric relaxation time (87.71 ms) and E/A ratio (1.04). In comparison to TDI, using standard 2D echocardiography leads to overdiagnosis of CCM.
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Affiliation(s)
| | - Orsolya Menyhárt
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary; Buda Health Center
| | | | - Árpád V Patai
- Interdisciplinary Gastroenterology Working Group, Semmelweis University, Budapest, Hungary; Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary.
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Wu PS, Wang YW, Tai CC, Hsieh YC, Lee PC, Huang CC, Huang YH, Hou MC, Lin HC, Lee KC. Early echocardiographic signs of diastolic dysfunction predict acute kidney injury in cirrhotic patients. J Chin Med Assoc 2020; 83:984-990. [PMID: 32889984 PMCID: PMC7647425 DOI: 10.1097/jcma.0000000000000422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cardiovascular dysfunction in cirrhotic patients affects survival and the development of cirrhotic complications. We aimed to evaluate potential echocardiographic parameters to predict mortality and acute kidney injury (AKI) in cirrhotic patients. METHODS A total of 103 cirrhotic patients who underwent echocardiography between February 2009 and August 2016 in Taipei Veterans General Hospital were retrospectively enrolled. Cardiac function was evaluated using transthoracic two-dimensional echocardiography with tissue Doppler imaging. Cox hazard regression analysis was used for assessing predictors for 1-year mortality and AKI within 1 year. RESULTS Baseline echocardiographic parameters were similar between survivors (n = 92) and nonsurvivors (n = 11). Lower serum levels of albumin, as well as higher albumin-bilirubin (ALBI) scores, Child-Pugh scores, and model for end-stage liver disease scores were observed in nonsurvivors. Cox proportional hazard regression analysis revealed Child-Pugh score as the only predictor of 1-year mortality. Baseline serum creatinine (Cr) > 1.5 mg/dL, total bilirubin > 2 mg/dL, and a higher E/e' ratio predict occurrence of AKI within 1 year. Among patients with serum Cr < 1.5 mg/dL, an increased atrial filling velocity and higher ALBI scores predict AKI occurrence within 1 year. CONCLUSION Severity of underlying liver disease but not echocardiographic parameters predicts 1-year mortality in cirrhosis. Early echocardiographic signs of diastolic dysfunction and higher ALBI scores may predict development of AKI in cirrhotic patients with serum Cr < 1.5 mg/dL.
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Affiliation(s)
- Pei-Shan Wu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Ying-Wen Wang
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Healthcare and Service Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Cheng-Chun Tai
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Yun-Cheng Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Chin-Chou Huang
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Address correspondence. Dr. Kuei-Chuan Lee, Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taiwan, ROC. E-mail address: (K.-C. Lee)
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Stundiene I, Sarnelyte J, Norkute A, Aidietiene S, Liakina V, Masalaite L, Valantinas J. Liver cirrhosis and left ventricle diastolic dysfunction: Systematic review. World J Gastroenterol 2019; 25:4779-4795. [PMID: 31528101 PMCID: PMC6718042 DOI: 10.3748/wjg.v25.i32.4779] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/10/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver cirrhosis is a chronic hepatic disease which is associated with cardiovascular abnormalities. Hyperdynamic circulation in liver cirrhosis causes functional and structural cardiac alterations. The prevalence of left ventricle diastolic dysfunction (LVDD) in cirrhotic patients ranges from 25.7% to as high as 81.4% as reported in different studies. In several studies the severity of diastolic dysfunction (DD) correlated with a degree of liver failure and the rate of dysfunction was higher in patients with decompensated cirrhosis compared with compensated. Future directions of comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for these patients. AIM To clarify the correlation between the severity of liver cirrhosis and left ventricle diastolic dysfunction in the existing literature. METHODS Through January and February of 2019 at Vilnius University we conducted a systematic review of the global existing literature on the prevalence of left ventricle diastolic dysfunction in patients with liver cirrhosis. We searched for articles in PubMed, Medline and Web of science databases. Articles were selected by using adequate inclusion and exclusion criteria. Our interest was the outcome of likely correlation between the severity of cirrhosis [evaluated by Child-Pugh classes, Model For End-Stage Liver Disease (MELD) scores] and left ventricle diastolic dysfunction [classified according to American Society of Echocardiography (ASE) guidelines (2009, 2016)], as well as relative risk of dysfunction in cirrhotic patients. Subgroup analyses were performed to evaluate the ratio and grades of left ventricle diastolic dysfunction with respect to cirrhosis severity. RESULTS A total of 1149 articles and abstracts met the initial search criteria. Sixteen articles which met the predefined eligibility criteria were included in the final analysis. Overall, 1067 patients (out of them 723 men) with liver cirrhosis were evaluated for left ventricle diastolic dysfunction. In our systemic analysis we have found that 51.2% of cirrhotic patients had left ventricle diastolic dysfunction diagnosed and the grade 1 was the most prevalent (59.2%, P < 0.001) among them, the grade 3 had been rarely diagnosed - only 5.1%. The data about the prevalence of diastolic dysfunction in cirrhotic patients depending on Child-Pugh Classes was available from 5 studies (365 patients overall) and only in 1 research diastolic dysfunction was found being associated with severity of liver cirrhosis (P < 0.005). We established that diastolic dysfunction was diagnosed in 44.6% of Child-Pugh A class patients, in 62% of Child B class and in 63.3% of Child C patients (P = 0.028). The proportion of patients with higher diastolic dysfunction grades increases in more severe cirrhosis presentation (P < 0.001). There was no difference between mean MELD scores in patients with and without diastolic dysfunction and in different diastolic dysfunction groups. In all studies diastolic dysfunction was more frequent in patients with ascites. CONCLUSION This systemic analysis suggests that left ventricle diastolic dysfunction is an attribute of liver cirrhosis which has not received sufficient attention from clinicians so far. Future suggestions of a comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for these patients and give hint for better understanding of the left ventricle diastolic dysfunction pathogenesis in liver cirrhosis.
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Affiliation(s)
- Ieva Stundiene
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
| | - Julija Sarnelyte
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
| | - Ausma Norkute
- Vilnius University, Institute of Clinical Medicine, Clinic of Internal diseases, Family medicine and Oncology, Vilnius University, Vilnius LT-03101, Lithuania
| | - Sigita Aidietiene
- Vilnius University, Institute of Clinical Medicine, Clinic of Cardiology and Angiology, Vilnius University, Vilnius LT-03101, Lithuania
| | - Valentina Liakina
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
- Vilnius Gediminas Technical University, Faculty of Fundamental Sciences, Department of Chemistry and Bioengineering, Vilnius LT-10223, Lithuania
| | - Laura Masalaite
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
| | - Jonas Valantinas
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
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Angeli P, Bernardi M, Villanueva C, Francoz C, Mookerjee RP, Trebicka J, Krag A, Laleman W, Gines P. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1781] [Impact Index Per Article: 254.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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Junge N, Junge C, Schröder J, Pfister ED, Leiskau C, Hohmann D, Beerbaum P, Baumann U. Pediatric cirrhotic cardiomyopathy: Impact on liver transplant outcomes. Liver Transpl 2018; 24:820-830. [PMID: 29637720 DOI: 10.1002/lt.25076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/12/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023]
Abstract
In adults, cirrhotic cardiomyopathy (CCM) has a significant incidence and impact on liver transplantation. For pediatric liver transplantation (pLT), data on liver-induced cardiac changes are scarce, and in particular, the comparison between cirrhotic and noncirrhotic liver disease has not been investigated. We retrospectively evaluated cardiac changes associated with CCM by echocardiography and 12-lead electrocardiogram in 198 pLT-candidates (median age 4.1 years) 4.2 before and 12 months after pLT. Results were correlated with the stage of liver fibrosis and cholestasis before transplantation. The left ventricular end-diastolic diameter (LVIDd) z score, left ventricular mass z score, and left ventricular mass index were significantly higher in cirrhotic patients (-0.10 versus 0.98, P < 0.001; -1.55 versus -0.42, P = 0.001; 78.99 versus 125.64 g/m2 , P = 0.001, respectively) compared with children with noncirrhotic liver disease. Pathological z scores (>2SDS) for the LVIDd occurred more frequently in cirrhotic patients compared with patients with noncirrhotic liver disease (31/169 versus 1/29; P = 0.03) and were significantly associated with cholestasis. All observed cardiac changes were reversible 1 year after pLT. Pathological LVIDd z scores correlated highly with intensive care unit (ICU) stay (9.6 days versus 17.1 days, respectively, P = 0.002) but not with patient survival pre-LT or post-LT. In contrast to other studies, prolonged QTc time was not associated with liver cirrhosis in our patients. In conclusion, CCM-associated cardiac changes in pLT candidates with cirrhotic liver disease are frequent, mild, and associated with cholestasis and reversible after pLT. They may impact peritransplant care and posttransplant hospitalization time. Further prospective evaluation is warranted. In particular, for QTc time prolongation etiological factors, possible protective effects of ursodeoxycholic acid treatment and the use as a screening parameter for CCM should be verified. Liver Transplantation 24 820-830 2018 AASLD.
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Affiliation(s)
| | - Claudia Junge
- Paediatric Cardiology and Intensive Medicine, Hannover Medical School, Hannover, Germany
| | | | | | | | - Dagmar Hohmann
- Paediatric Cardiology and Intensive Medicine, Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Paediatric Cardiology and Intensive Medicine, Hannover Medical School, Hannover, Germany
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Rimbaş RC, Baldea SM, Guerra RDGA, Visoiu SI, Rimbaş M, Pop CS, Vinereanu D. New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:562-574. [PMID: 29306590 DOI: 10.1016/j.ultrasmedbio.2017.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 06/07/2023]
Abstract
There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child-Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.
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Affiliation(s)
- Roxana Cristina Rimbaş
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Sorina Mihăilă Baldea
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Mihai Rimbaş
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Corina Silvia Pop
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, University and Emergency Hospital, Bucharest, Romania
| | - Dragoş Vinereanu
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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15
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Barbosa M, Guardado J, Marinho C, Rosa B, Quelhas I, Lourenço A, Cotter J. Cirrhotic cardiomyopathy: Isn't stress evaluation always required for the diagnosis? World J Hepatol 2016; 8:200-206. [PMID: 26839643 PMCID: PMC4724582 DOI: 10.4254/wjh.v8.i3.200] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/02/2015] [Accepted: 12/17/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the proportion of patients with cirrhotic cardiomyopathy (CCM) evaluated by stress echocardiography and investigating its association with the severity of liver disease. METHODS A cross-sectional study was conducted. Cirrhotic patients without risk factors for cardiovascular disease were included. Data regarding etiology and severity of liver disease (Child-Pugh score and model for end-stage liver disease), presence of ascites and gastroesophageal varices, pro-brain natriuretic peptide (pro-BNP) and corrected QT (QTc) interval were collected. Dobutamine stress echocardiography (conventional and tissue Doppler imaging) was performed. CCM was considered present when diastolic and/or systolic dysfunction was diagnosed at rest or after pharmacological stress. Therapy interfering with cardiovascular system was suspended 24 h before the examination. RESULTS Twenty-six patients were analyzed, 17 (65.4%) Child-Pugh A, mean model for end-stage liver disease (MELD) score of 8.7. The global proportion of patients with CCM was 61.5%. At rest, only 2 (7.7%) patients had diastolic dysfunction and none of the patients had systolic dysfunction. Dobutamine stress echocardiography revealed the presence of diastolic dysfunction in more 6 (23.1%) patients and of systolic dysfunction in 10 (38.5%) patients. QTc interval prolongation was observed in 68.8% of the patients and increased pro-BNP levels in 31.2% of them. There was no association between the presence of CCM and liver impairment assessed by Child-Pugh score or MELD (P = 0.775, P = 0.532, respectively). Patients with QTc interval prolongation had a significant higher rate of gastroesophageal varices comparing with those without QTc interval prolongation (95.0% vs 50.0%, P = 0.028). CONCLUSION CCM is a frequent complication of cirrhosis that is independent of liver impairment. Stress evaluation should always be performed, otherwise it will remain an underdiagnosed condition.
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Affiliation(s)
- Mara Barbosa
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
| | - Joana Guardado
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
| | - Carla Marinho
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
| | - Bruno Rosa
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
| | - Isabel Quelhas
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
| | - António Lourenço
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
| | - José Cotter
- Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
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Sampaio F, Pimenta J. Left ventricular function assessment in cirrhosis: Current methods and future directions. World J Gastroenterol 2016; 22:112-125. [PMID: 26755864 PMCID: PMC4698479 DOI: 10.3748/wjg.v22.i1.112] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/29/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Cirrhotic cardiomyopathy has been defined as a chronic cardiac dysfunction in patients with cirrhosis characterized by impaired contractile responsiveness to stress and/or altered diastolic relaxation with electrophysiological abnormalities in the absence of other known cardiac disease. Non-invasive cardiovascular imaging modalities play a major role in unmasking systolic and diastolic dysfunction in patients with cirrhosis. Echocardiography has been the most commonly used modality for assessing myocardial function in these patients. Conventional echocardiographic indices rely on several assumptions that may limit their applicability in patients with a hyperdynamic circulation. Newer imaging modalities may contribute to a more accurate diagnosis of cardiovascular abnormalities in cirrhotic patients, thereby influencing clinical management. We aimed to review the different non-invasive imaging technologies currently used for assessing left ventricular systolic and diastolic function in cirrhosis, as well as to describe new imaging modalities with potential clinical applicability in the near future.
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Filì D, Falletta C, Luca A, Hernandez Baravoglia C, Clemenza F, Miraglia R, Scardulla C, Tuzzolino F, Vizzini G, Gridelli B, Bosch J. Circulatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: Relationship with diastolic dysfunction. Dig Liver Dis 2015; 47:1052-8. [PMID: 26427586 DOI: 10.1016/j.dld.2015.08.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/25/2015] [Accepted: 08/27/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cirrhotic cardiomyopathy may lead to heart failure in stressful circumstances, such as after transjugular intrahepatic portosystemic shunt (TIPS) placement. AIM To examine whether acute volume expansion predicts haemodynamic changes after TIPS and elicits signs of impending heart failure. METHODS We prospectively evaluated refractory ascites patients (group A) and compensated cirrhotics (group B), who underwent echocardiography, NT-proBNP measurement, and heart catheterization before and after volume load; group A repeated measurements after TIPS. RESULTS 15 patients in group A (80% male; 54±12.4 years) and 8 in group B (100% male; 56±6.2 years) were enrolled. Echocardiography disclosed diastolic dysfunction in 30% and 12.5%, respectively. In group A, volume load and TIPS induced a significant increase in right atrial, mean pulmonary, capillary wedge pressure and cardiac index, and a decrease in systemic vascular resistance (respectively, 4.7±2.8 vs. 9.9±3.6 mmHg; 13.3±3.5 vs. 21.9±5.9 mmHg; 8.3±3.4 vs. 15.4±4.7 mmHg; 3.7±0.7 vs. 4.6±11 t/min/m2; 961±278 vs. 767±285 dynscm(-5); and 10.1±3.3 vs. 14.2±3.4 mmHg; 17.5±4 vs. 25.2±4.2 mmHg; 12.3±4 vs. 19.3±3.4 mmHg; 3.4±0.8 vs. 4.5±0.91l t/min/m2; 779±62 vs. 596±199 dynscm(-5), p<0.001 for all pairs). At 24h, cardiopulmonary pressures returned towards baseline. CONCLUSIONS Acute volume expansion predicted haemodynamic changes immediately after TIPS. All patients had adequate haemodynamic adaptation to TIPS; none developed signs of heart failure.
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Affiliation(s)
- Daniela Filì
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy.
| | - Calogero Falletta
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Angelo Luca
- Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Cesar Hernandez Baravoglia
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Francesco Clemenza
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Roberto Miraglia
- Radiology Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Cesare Scardulla
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Fabio Tuzzolino
- Department of Economic, Business and Statistical Sciences, University of Palermo, Palermo, Italy
| | - Giovanni Vizzini
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Bruno Gridelli
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Jaime Bosch
- Liver Unit, Hospital Clínic, University of Barcelona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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Falletta C, Filì D, Nugara C, Di Gesaro G, Minà C, Baravoglia CMH, Romano G, Scardulla C, Tuzzolino F, Vizzini G, Clemenza F. Diastolic dysfunction diagnosed by tissue Doppler imaging in cirrhotic patients: Prevalence and its possible relationship with clinical outcome. Eur J Intern Med 2015; 26:830-4. [PMID: 26525531 DOI: 10.1016/j.ejim.2015.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 08/25/2015] [Accepted: 10/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cirrhotic cardiomyopathy has been characterized by impaired contractile response to stress and/or altered diastolic relaxation, with electrophysiological abnormalities in the absence of known cardiac disease. However, the clinical significance of diastolic dysfunction (DDF) in cirrhotic patients has not been clarified. METHODS We studied 84 cirrhotic patients with normal systolic function to evaluate the prevalence of DDF using tissue Doppler imaging, and to investigate the possible correlation of DDF with outcomes (hospitalization, death) and with the specific causes of death. RESULTS The mean follow-up was 10±8months. DDF was diagnosed in 22 patients (26.2%). Patients with DDF more frequently had ascites (90.9% vs. 64.5 %; p=0.026), lower levels of albumin (OR: 5.39; p=0.004), higher NT-proBNP levels, and longer QTc interval (464±23ms vs. 452±30ms; p=0.039). At follow-up, patients with DDF did not have a higher incidence of adverse events in terms of hospitalization and death. CONCLUSIONS The presence of diastolic dysfunction has not been found to be clearly associated with outcome, and prognosis has been determined primarily by the severity of liver disease.
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Affiliation(s)
- Calogero Falletta
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Daniela Filì
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Cinzia Nugara
- Division of Cardiology A.O.U.P. Paolo Giaccone, Palermo, Italy
| | - Gabriele Di Gesaro
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Chiara Minà
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Cesar Mario Hernandez Baravoglia
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Giuseppe Romano
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Cesare Scardulla
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Fabio Tuzzolino
- Research Office, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Giovanni Vizzini
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Francesco Clemenza
- Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
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Ruiz-del-Árbol L, Serradilla R. Cirrhotic cardiomyopathy. World J Gastroenterol 2015; 21:11502-11521. [PMID: 26556983 PMCID: PMC4631957 DOI: 10.3748/wjg.v21.i41.11502] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/17/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
During the course of cirrhosis, there is a progressive deterioration of cardiac function manifested by the disappearance of the hyperdynamic circulation due to a failure in heart function with decreased cardiac output. This is due to a deterioration in inotropic and chronotropic function which takes place in parallel with a diastolic dysfunction and cardiac hypertrophy in the absence of other known cardiac disease. Other findings of this specific cardiomyopathy include impaired contractile responsiveness to stress stimuli and electrophysiological abnormalities with prolonged QT interval. The pathogenic mechanisms of cirrhotic cardiomyopathy include impairment of the b-adrenergic receptor signalling, abnormal cardiomyocyte membrane lipid composition and biophysical properties, ion channel defects and overactivity of humoral cardiodepressant factors. Cirrhotic cardiomyopathy may be difficult to determine due to the lack of a specific diagnosis test. However, an echocardiogram allows the detection of the diastolic dysfunction and the E/e′ ratio may be used in the follow-up progression of the illness. Cirrhotic cardiomyopathy plays an important role in the pathogenesis of the impairment of effective arterial blood volume and correlates with the degree of liver failure. A clinical consequence of cardiac dysfunction is an inadequate cardiac response in the setting of vascular stress that may result in renal hypoperfusion leading to renal failure. The prognosis is difficult to establish but the severity of diastolic dysfunction may be a marker of mortality risk. Treatment is non-specific and liver transplantation may normalize the cardiac function.
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Nasr FM, Metwaly A, khalik AA, Darwish H. Cardiac dysfunction in liver cirrhosis: A tissue Doppler imaging study from Egypt. Electron Physician 2015; 7:1135-43. [PMID: 26396725 PMCID: PMC4578531 DOI: 10.14661/2015.1135-1143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 07/27/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Patients with liver cirrhosis suffer from various cardiac abnormalities, which may influence their outcome. Tissue Doppler recording of the mitral and tricuspid annular diastolic velocities can be used to assess diastolic function accurately. There has been very little published information regarding RV diastolic function in liver cirrhosis. This study is aimed at evaluating right and left ventricular systolic and diastolic functions in post hepatitis C liver cirrhosis patients using conventional echocardiography and tissue Doppler imaging. METHODS This study was conducted on 75 adults from inpatient and outpatient services of the Theodor Bilharz Research Institute (TBRI) hospital. They were divided into two groups: Group 1 included 50 patients with post hepatitis C liver cirrhosis; and Group 2 included 25 normal adults serving as a control group. All patients and normal volunteers were subjected to clinical examination, laboratory evaluation, abdominal ultrasonography and echocardiographic studies with tissue Doppler imaging for evaluation of left and right ventricular systolic and diastolic functions. RESULTS The mitral flow showed significant increase in A wave velocity, as well as DT and IVRT with a significant decrease in E/A ratio in Group 1 compared to Group 2 (P<0.01). The tricuspid flow also showed a significant increase in A wave velocity (P<0.01) and DT (P<0.05) in addition to a significant decrease in E wave velocity and E/A ratio (P<0.01) in Group 1 as compared to Group 2. At the mitral annulus, we found a significant increase in average Aa velocity, E/Ea ratio and average systolic wave velocity S, in addition to a statistically significant decrease in the average Ea velocity and average Ea/Aa (P<0.01) in Group 1 as compared to Group 2. At the tricuspid annulus, there were significant increases in the average Aa velocity (P<0.01), S velocity (P<0.01) and E/Ea (P<0.05) together with a statistically significant decrease in the average Ea/Aa and average Ea velocity (P<0.01) in Group 1 compared to Group 2. CONCLUSION It is important to evaluate the cardiovascular function in every patient with cirrhosis, especially if the patient is a candidate for any intervention that may affect haemodynamics.
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Affiliation(s)
| | - Amna Metwaly
- Intesive Care unit, Theodor Bilharz Research Institute, Giza, Egypt
| | | | - Hesham Darwish
- Intesive Care unit, Theodor Bilharz Research Institute, Giza, Egypt
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Sampaio F, Lamata P, Bettencourt N, Alt SC, Ferreira N, Kowallick JT, Pimenta J, Kutty S, Fraga J, Steinmetz M, Bettencourt P, Gama V, Schuster A. Assessment of cardiovascular physiology using dobutamine stress cardiovascular magnetic resonance reveals impaired contractile reserve in patients with cirrhotic cardiomyopathy. J Cardiovasc Magn Reson 2015; 17:61. [PMID: 26187817 PMCID: PMC4506630 DOI: 10.1186/s12968-015-0157-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 06/22/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver cirrhosis has been shown to affect cardiac performance. However cardiac dysfunction may only be revealed under stress conditions. The value of non-invasive stress tests in diagnosing cirrhotic cardiomyopathy is unclear. We sought to investigate the response to pharmacological stimulation with dobutamine in patients with cirrhosis using cardiovascular magnetic resonance. METHODS Thirty-six patients and eight controls were scanned using a 1.5 T scanner (Siemens Symphony TIM; Siemens, Erlangen, Germany). Conventional volumetric and feature tracking analysis using dedicated software (CMR42; Circle Cardiovascular Imaging Inc, Calgary, Canada and Diogenes MRI; Tomtec; Germany, respectively) were performed at rest and during low to intermediate dose dobutamine stress. RESULTS Whilst volumetry based parameters were similar between patients and controls at rest, patients had a smaller increase in cardiac output during stress (p = 0.015). Ejection fraction increase was impaired in patients during 10 μg/kg/min dobutamine as compared to controls (6.9 % vs. 16.5 %, p = 0.007), but not with 20 μg/kg/min (12.1 % vs. 17.6 %, p = 0.12). This was paralleled by an impaired improvement in circumferential strain with low dose (median increase of 14.4 % vs. 30.9 %, p = 0.03), but not with intermediate dose dobutamine (median increase of 29.4 % vs. 33.9 %, p = 0.54). There was an impaired longitudinal strain increase in patients as compared to controls during low (median increase of 6.6 % vs 28.6 %, p < 0.001) and intermediate dose dobutamine (median increase of 2.6%vs, 12.6 % p = 0.016). Radial strain response to dobutamine was similar in patients and controls (p > 0.05). CONCLUSION Cirrhotic cardiomyopathy is characterized by an impaired cardiac pharmacological response that can be detected with magnetic resonance myocardial stress testing. Deformation analysis parameters may be more sensitive in identifying abnormalities in inotropic response to stress than conventional methods.
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MESH Headings
- Aged
- Cardiomyopathies/diagnosis
- Cardiomyopathies/etiology
- Cardiomyopathies/physiopathology
- Cardiotonic Agents/administration & dosage
- Case-Control Studies
- Dobutamine/administration & dosage
- Female
- Humans
- Image Interpretation, Computer-Assisted
- Liver Cirrhosis/complications
- Liver Cirrhosis/diagnosis
- Magnetic Resonance Imaging, Cine/methods
- Male
- Middle Aged
- Myocardial Contraction
- Observer Variation
- Predictive Value of Tests
- Reproducibility of Results
- Software
- Stroke Volume
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/diagnosis
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Left
- Ventricular Function, Right
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Affiliation(s)
- Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502 Vila Nova de Gaia, Espinho, Portugal.
- University of Porto Medical School, Porto, Portugal.
| | - Pablo Lamata
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, Kings College London, St. Thomas' Hospital, London, UK.
| | - Nuno Bettencourt
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502 Vila Nova de Gaia, Espinho, Portugal.
- University of Porto Medical School, Porto, Portugal.
| | - Sophie Charlotte Alt
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg-August University, Göttingen, Germany.
| | - Nuno Ferreira
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502 Vila Nova de Gaia, Espinho, Portugal.
| | - Johannes Tammo Kowallick
- Institute for Diagnostic and Interventional Radiology, Georg-August University, Göttingen, Germany.
- DZHK (German Centre for Cardiovascular Research), Göttingen, Germany.
| | - Joana Pimenta
- University of Porto Medical School, Porto, Portugal.
| | - Shelby Kutty
- University of Nebraska Medical Center/ Children's Hospital and Medical Center, Omaha, NE, USA.
| | - José Fraga
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, Espinho, Portugal.
| | - Michael Steinmetz
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg-August University, Göttingen, Germany.
- DZHK (German Centre for Cardiovascular Research), Göttingen, Germany.
| | | | - Vasco Gama
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502 Vila Nova de Gaia, Espinho, Portugal.
| | - Andreas Schuster
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, Kings College London, St. Thomas' Hospital, London, UK.
- DZHK (German Centre for Cardiovascular Research), Göttingen, Germany.
- Department of Cardiology and Pneumology, Georg-August University, Göttingen, Germany.
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Karagiannakis DS, Papatheodoridis G, Vlachogiannakos J. Recent advances in cirrhotic cardiomyopathy. Dig Dis Sci 2015; 60:1141-1151. [PMID: 25404411 DOI: 10.1007/s10620-014-3432-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/08/2014] [Indexed: 12/15/2022]
Abstract
Cirrhotic cardiomyopathy, a cardiac dysfunction presented in patients with cirrhosis, represents a recently recognized clinical entity. It is characterized by altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, in particular prolongation of the QT interval. Several mechanisms seem to be involved in the pathogenesis of cirrhotic cardiomyopathy, including impaired function of beta-receptors, altered transmembrane currents, and overproduction of cardiodepressant factors, like nitric oxide, tumor necrosis factor α, and endogenous cannabinoids. Diastolic dysfunction is the first manifestation of cirrhotic cardiomyopathy and reflects the increased stiffness of the cardiac mass, which leads to delayed left ventricular filling. On the other hand, systolic incompetence is presented later, is usually unmasked during pharmacological or physical stress, and predisposes to the development of hepatorenal syndrome. The prolongation of QT is found in about 50 % of cirrhotic patients, but rarely leads to fatal arrhythmias. Cirrhotics with blunted cardiac function seem to have poorer survival rates compared to those without, and the risk is particularly increased during the insertion of transjugular intrahepatic portosystemic shunt or liver transplantation. Till now, there is no specific treatment for the management of cirrhotic cardiomyopathy. New agents, targeting to its pathogenetical mechanisms, may play some role as future therapeutic options.
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Affiliation(s)
- Dimitrios S Karagiannakis
- Department of Gastroenterology, Medical School of Athens University, Laiko General Hospital, 17 Agiou Thoma Street, 11527, Athens, Greece,
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Karagiannakis DS, Vlachogiannakos J, Anastasiadis G, Vafiadis-Zouboulis I, Ladas SD. Diastolic cardiac dysfunction is a predictor of dismal prognosis in patients with liver cirrhosis. Hepatol Int 2014; 8:588-594. [PMID: 26202764 DOI: 10.1007/s12072-014-9544-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 05/13/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Left ventricular diastolic dysfunction (LVDD) constitutes the prominent characteristic of cirrhotic cardiomyopathy, but its relevance on the clinical course of cirrhotic patients has not been clearly defined. The aim of the study was to evaluate the relationship of LVDD with the severity and etiology of liver disease and to investigate whether it affects the outcome of cirrhotic patients. METHODS Cardiac function of 45 cirrhotics was studied by a tissue Doppler imaging echocardiography. Diagnosis of LVDD was made according to the latest guidelines of the American Society of Echocardiography. All patients were followed up for a period of 2 years. Death or liver transplantation was the endpoint of the study. RESULTS LVDD was found in 17 (38 %) of 45 patients. Its presence was not found to be associated with the etiology and stage of cirrhosis, but its severity was directly correlated with the Child-Pugh score. At the end of follow-up, 14 patients had died; 9 had LVDD (9/17, 53 %) and 5 had not (5/28, 18 %). Patients who died at the beginning of observation period had a higher Child-Pugh and MELD score, higher BNP, lower albumin and more prolonged QTc. On Kaplan-Meier analysis, patients with LVDD had statistically significantly worse prognosis compared to those without (p = 0.013, log rank: 5.495). Low albumin values (p = 0.003) and presence of LVDD (p = 0.017) were independent predictive factors of mortality. CONCLUSIONS LVDD is a common complication of cirrhosis. As its development seems to be related to a worse prognosis, patients with LVDD must be under a strict follow-up.
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Affiliation(s)
- Dimitrios S Karagiannakis
- Academic Department of Gastroenterology, Medical School of Athens, Laikon General Hospital, 17 Aghiou Thoma Street, 11527, Athens, Greece.
| | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of Athens, Laikon General Hospital, 17 Aghiou Thoma Street, 11527, Athens, Greece.
| | - Georgios Anastasiadis
- Department of Cardiology, Laikon General Hospital, 17 Aghiou Thoma Street, 11527, Athens, Greece.
| | - Irini Vafiadis-Zouboulis
- Academic Department of Gastroenterology, Medical School of Athens, Laikon General Hospital, 17 Aghiou Thoma Street, 11527, Athens, Greece.
| | - Spiros D Ladas
- Academic Department of Gastroenterology, Medical School of Athens, Laikon General Hospital, 17 Aghiou Thoma Street, 11527, Athens, Greece.
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26
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Sampaio F, Pimenta J, Bettencourt N, Fontes-Carvalho R, Silva AP, Valente J, Bettencourt P, Fraga J, Gama V. Systolic dysfunction and diastolic dysfunction do not influence medium-term prognosis in patients with cirrhosis. Eur J Intern Med 2014; 25:241-6. [PMID: 24485543 DOI: 10.1016/j.ejim.2014.01.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 01/10/2014] [Accepted: 01/13/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Myocardial dysfunction has been described in patients with cirrhosis and may contribute to haemodynamic disturbances in advanced disease states. However, the prognostic impact of cardiac systolic and diastolic dysfunction in cirrhosis is controversial. We aimed to evaluate the performance of echocardiographic parameters of cardiac function as medium-term prognostic markers, in a cohort of cirrhotic patients. METHODS Ninety-eight patients (52 discharged after hospitalization for decompensated cirrhosis and 46 ambulatory) were prospectively evaluated. A comprehensive echocardiographic study, including tissue-Doppler and speckle tracking analysis, was performed at baseline. Patients were followed-up for 6 months for the occurrence of death. RESULTS Twenty patients died during the follow-up. None of the echocardiographic parameters were associated with the occurrence of death. A Child score>10 points (HR 13.1, 95% CI 3.79-45.0, p<0.001) and a mean arterial pressure below the median (HR 3.2, 95% CI 1.14-8.80, p=0.028) were the only independent predictors of mortality in Cox regression multivariate analysis. In previously hospitalized patients, cardiac output, C-reactive protein and albumin levels were associated with 6-month mortality in univariate analysis; this association was lost after adjusting for Child score. CONCLUSIONS Medium-term mortality in cirrhosis seems to be mainly determined by liver disease severity rather than by myocardial dysfunction. Modern echocardiographic indices of systolic and diastolic function do not seem to be useful in identifying patients at increased risk of dying.
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Affiliation(s)
- Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal; University of Porto Medical School, Al. Prof. Hernani Monteiro, 4200-319 Porto, Portugal.
| | - Joana Pimenta
- University of Porto Medical School, Al. Prof. Hernani Monteiro, 4200-319 Porto, Portugal.
| | - Nuno Bettencourt
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal; University of Porto Medical School, Al. Prof. Hernani Monteiro, 4200-319 Porto, Portugal.
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal; University of Porto Medical School, Al. Prof. Hernani Monteiro, 4200-319 Porto, Portugal.
| | - Ana-Paula Silva
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal.
| | - João Valente
- Internal Medicine Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal.
| | - Paulo Bettencourt
- University of Porto Medical School, Al. Prof. Hernani Monteiro, 4200-319 Porto, Portugal.
| | - José Fraga
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal.
| | - Vasco Gama
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal.
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Abstract
Candidates for abdominal transplant undergo a pretransplant evaluation to identify associated conditions that may require intervention or that may influence a patient's candidacy for transplant. Coronary artery disease is prevalent in candidates for abdominal organ transplantation. The optimal approach to identify and manage coronary artery disease in the peri-transplant period is currently unclear. In liver transplant candidates portopulmonary hypertension and hepatopulmonary syndrome should be screened for. Identification of the patient who is too sick to benefit from transplant is problematic; with no good evidence available decisions should be individualized and made after multidisciplinary discussion.
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Affiliation(s)
- James Y Findlay
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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28
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Sampaio F, Pimenta J, Bettencourt N, Fontes-Carvalho R, Silva AP, Valente J, Bettencourt P, Fraga J, Gama V. Systolic and diastolic dysfunction in cirrhosis: a tissue-Doppler and speckle tracking echocardiography study. Liver Int 2013; 33:1158-65. [PMID: 23617332 DOI: 10.1111/liv.12187] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 03/18/2013] [Accepted: 04/01/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Cardiac dysfunction has been described in patients with cirrhosis. Conventional echocardiographic methods are frequently unable to detect abnormalities at rest and have limitations. We aimed to evaluate cardiac function in cirrhosis patients assessing: (i) left ventricular systolic function using speckle-tracking imaging; (ii) diastolic function using a tissue-Doppler based algorithm and comparing it with previously proposed definition of diastolic dysfunction (DD). METHODS We included 109 hospitalized and ambulatory patients with cirrhosis and 18 healthy controls. Detailed echocardiographic evaluation was performed including tissue-Doppler and speckle-tracking analysis. RESULTS Peak systolic longitudinal strain (PLS) was lower in patients [-19.99% (-21.88 to -18.71) vs -22.02% (-23.10 to -21.18), P = 0.003]. Ejection fraction was similar in patients and controls [64% (59-67) vs 61% (60-65), P = 0.42)]. Based on mitral-flow pattern, DD was present in 44 patients (40.4%). Patients without DD had higher cardiac output compared with those with DD [6.4 L/min (5.4-7.2) vs 5.6 L/min (4.6-6.8), P = 0.02]. Using a tissue-Doppler based definition, the prevalence of DD was 16.5%. No differences in haemodynamic variables were found in patients with and without this definition of DD. The agreement between the two definitions of DD was weak (kappa = 0.24, P = 0.003). Echocardiographic abnormalities in systolic and diastolic function were not different in compensated vs decompensated patients in different Child-Pugh classes or cirrhosis aetiologies. CONCLUSIONS Patients with cirrhosis have systolic and diastolic cardiac dysfunction at rest. Newer echocardiographic techniques may identify patients with functional impairment more accurately than conventional methods, which are more influenced by flow conditions.
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Affiliation(s)
- Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Espinho, Portugal.
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Pellicori P, Torromeo C, Calicchia A, Ruffa A, Di Iorio M, Cleland JGF, Merli M. Does cirrhotic cardiomyopathy exist? 50 years of uncertainty. Clin Res Cardiol 2013; 102:859-64. [PMID: 23995321 DOI: 10.1007/s00392-013-0610-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 08/14/2013] [Indexed: 02/08/2023]
Abstract
Subtle abnormalities of cardiac structure or function are often identified in patients with liver cirrhosis and have been termed cirrhotic cardiomyopathy. However, in the absence of a precise definition, its diagnosis remains a challenge. Cardiac dysfunction in patients with cirrhosis can often be attributed to concomitant diseases such as hypertension, ischaemic heart disease or excess alcohol consumption in many patients. Further research is required to identify the existence, origin and importance of abnormal cardiac function due specifically to liver disease. Cardiac dysfunction may be masked by treatments given to cirrhotic patients, such as mineral-corticoid receptor antagonists, or by co-existing conditions, such as anaemia. New imaging tests or plasma biomarkers might be able to detect abnormal cardiac function at an early stage of its development.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre MRTDS (Daisy) Building, Entrance 2 Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK,
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Sampaio F, Pimenta J, Bettencourt N, Fontes-Carvalho R, Silva AP, Valente J, Bettencourt P, Fraga J, Gama V. Left atrial function is impaired in cirrhosis: a speckle tracking echocardiographic study. Hepatol Int 2013. [PMID: 26202416 DOI: 10.1007/s12072-013-9469-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Abnormalities in left ventricular systolic and diastolic function have been described in patients with cirrhosis. There are no studies on left atrial (LA) function in these patients. We aimed to evaluate LA function in cirrhosis patients using myocardial deformation imaging. METHODS We included 111 hospitalized and ambulatory patients with cirrhosis and 18 healthy controls. A comprehensive echocardiographic evaluation was performed; LA strain was assessed using velocity vector imaging. RESULTS Peak atrial longitudinal strain at the end of ventricular systole was lower in patients [41.9 % (34.4-51.0) vs. 48.0 % (42.0-57.1), p = 0.02]. No differences were found in atrial strain before atrial contraction in patients and controls [17.5 % (14.3-22.4) vs. 20.7 % (14.1-26.3), p = 0.14]. On multivariate linear regression analysis, E' velocity was the only variable independently associated with peak atrial longitudinal strain (R (2) = 47 %). No correlation was found between the LA volume index (LAVI) and peak atrial longitudinal strain (r = -0.136, p = 0.219). Peak atrial longitudinal strain performed better than LAVI in identifying patients with elevated filling pressures (AUC = 0.81 vs. 0.52). CONCLUSIONS Patients with cirrhosis have abnormal atrial reservoir function, which may be related to the same factors associated with impaired ventricular relaxation. LA enlargement in cirrhosis may not reflect elevated filling pressures and should not be used as an isolated marker of diastolic dysfunction. The atrial "pump" function does not seem to be affected in cirrhosis patients.
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Affiliation(s)
- Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal.
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal.
| | - Joana Pimenta
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Nuno Bettencourt
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Ana Paula Silva
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| | - João Valente
- Internal Medicine Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| | - Paulo Bettencourt
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - José Fraga
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| | - Vasco Gama
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
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