Cardiac morbidity and mortality related to orthotopic liver transplantation

Therapondos, George; Flapan, Andrew D.; Plevris, John; Hayes, Peter

doi:10.1002/lt.20298

Cited by 153 publications

(112 citation statements)

References 132 publications

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“…There is no single diagnostic test that can identify patients with cirrhotic cardiomyopathy and predict who will develop postoperative complications [42,43] . Furthermore, there is no comprehensive data that exists to guide the preoperative cardiac assessment of patients undergoing consideration for liver transplantation.…”

Section: Diagnosismentioning

confidence: 99%

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Rahman

Mallett

2015

WJH

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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. 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.

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Section: Diagnosismentioning

confidence: 99%

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Rahman

Mallett

2015

WJH

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“…This, when coupled with various metabolic abnormalities such as electrolyte imbalance, surgical stress, and graft production of cardiac-depressant cytokines such as TNF-a, may be the explanation for the high prevalence of cardiac morbidity in the posttransplant period despite no evidence of cardiac dysfunction on 2-dimensional and dobutamine stress echocardiography before surgery [87]. Diastolic dysfunction becomes more pronounced in the first 3 months posttransplant, possibly owing to increased ventricular hypertrophy [89]. When followed long-term for more than 1 year, there is complete reversal of cardiac changes in the posttransplant patients [90].…”

Section: Clinical Presentations and Consequences Of Cirrhotic Cardiommentioning

confidence: 99%

Cirrhotic cardiomyopathy

2008

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Cirrhotic cardiomyopathy is a recently recognized condition in cirrhosis consisting of systolic incompetence under condition of stress, diastolic dysfunction related to altered diastolic relaxation, and electrophysiological abnormalities in the absence of any known cardiac disease. It can be diagnosed by using a combination of electrocardiograph, 2-dimensional echocardiography, and various serum markers such as brain natriuretic factor. The underlying pathogenetic mechanisms include abnormalities in the b-adrenergic signaling pathway, altered cardiomyocyte membrane fluidity, increased myocardial fibrosis, cardiomyocyte hypertrophy, and ion channel defects. Various compounds for which levels are elevated in cirrhosis such as nitric oxide and carbon monoxide can also exert a negative inotropic effect on the myocardium, whereas excess sodium and volume retention can lead to myocardial hypertrophy. Various toxins can also aggravate the ion channel defects, thereby widening the QRS complex causing prolonged QT intervals. Clinically, systolic incompetence is most evident when cirrhotic patients are placed under stress, whether physical or pharmacological, or when the extent of peripheral arterial vasodilatation demands an increased cardiac output as in the case of bacterial infections. Acute volume overload such as immediately after insertion of a transjugular intrahepatic portosystemic shunt or after liver transplantation can also tip these cirrhotic patients into cardiac failure. Treatment of cirrhotic cardiomyopathy is unsatisfactory. There is some evidence that b-blockade may help some cirrhotic patients with baseline prolonged QT interval. Long-term aldosterone antagonism may help reduce myocardial hypertrophy. Future studies should include further elucidation of pathogenetic mechanisms so as to develop effective treatment strategies.

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“…Cardiac related causes account for %15-7 of all deaths after liver transplantation [8,26]. Up to %56 of patients with liver cirrhosis, most of them with no previous history of cardiac disease, develop clinical or radiographic evidence of pulmonary edema during their posttransplantation hospital course [27].…”

Section: Post-interventional Cardiac Complications Can We Add Somethmentioning

confidence: 99%

Untitled

2016

BAOJMN

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AimTo assess noninvasively the left ventricular filling pressure in patients with liver cirrhosis. MethodsThirty-five patients with liver cirrhosis were enrolled in the study in addition to 16 age-and sex-matched controls. All participants were subjected to full echocardiographic assessment. Evaluation of the left ventricular diastolic function and filling pressure was made using both the conventional and tissue Doppler imaging. ResultsHeart rate was significantly higher in patients with liver cirrhosis compared with the controls (86 ± 6.5 bpm vs 72± 4, P = 0.04).The mitral E/A ratio was significantly lower in patients with liver cirrhosis (mean age, 53±6 years) and was correlated with the severity of liver impairment (P = 0.04, r = -0.335). Compared to the controls, the left ventricular filling pressure was significantly elevated in patients with liver cirrhosis (10±3 vs 9±1, P = 0.002). All patients with elevated filling pressure (75% of them were females) had more advanced form of liver impairment, and were categorized as having normal left ventricular diastolic functions using the mitral inflow indexes. ConclusionsThe resting left ventricular filling pressure is elevated in patients with liver cirrhosis. Further studies are warranted to determine whether these patients are more prone to the development of cardiac complications (mainly pulmonary edema) following liver transplantation. The use of multiple parameters, rather than the mitral indexes only, to assess the left ventricular diastolic functions in patients with liver cirrhosis is recommended.

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Cardiac morbidity and mortality related to orthotopic liver transplantation

Cited by 153 publications

References 132 publications

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Cirrhotic cardiomyopathy

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