Cirrhotic cardiomyopathy: Appraisal of the original and revised criteria in predicting posttransplant cardiac outcomes

Abstract

Cardiovascular disease (CVD) significantly contributes to morbidity and mortality after liver transplantation (LT). Cirrhotic cardiomyopathy (CCM) is a risk factor for CVD after transplant. CCM criteria were originally introduced in 2005 with a revision proposed in 2020 reflecting echocardiographic technology advancements. This study assesses the two criteria sets in predicting major adverse cardiac events (MACE) after transplant. This single‐center retrospective study reviewed adult LT recipients between January 1, 2009, and December 31, 2018. Patients with insufficient pre‐LT echocardiographic data, prior ischemic heart disease, portopulmonary hypertension, or longitudinal care elsewhere were excluded. The primary composite outcome was MACE (arrhythmia, heart failure, cardiac arrest, and/or cardiac death) after transplant. Of 1165 patients, 210 met the eligibility criteria. CCM was present in 162 patients (77%) per the original criteria and 64 patients (30%) per the revised criteria. There were 44 MACE and 31 deaths in the study period. Of the deaths, 38.7% occurred secondary to CVD. CCM defined by the original criteria was not associated with MACE after LT (p = 0.21), but the revised definition was significantly associated with MACE (hazard ratio [HR], 1.93; 95% confidence interval, 1.05–3.56; p = 0.04) on multivariable analysis. Echocardiographic variable analysis demonstrated low septal e’ as the most predictive variable for MACE after LT (HR, 3.45; p < 0.001). CCM, only when defined by the revised criteria, was associated with increased risk for MACE after LT, validating the recently revised CCM definition. Abnormal septal e’, reflecting impaired relaxation, appears to be the most predictive echocardiographic criterion for MACE after LT.

Left ventricular diastolic dysfunction per the 2016 ASE criteria and mortality after liver transplant in patients with end stage liver disease: a Systematic Review and Metanalysis

“…However, differences in all-cause mortality were not found, as in our study. (32,33) Many of the studies we found in our systematic review reported con icting results on a relationship between LVDD and worse outcomes; however, we found high heterogeneity in the criteria used to de ne LVDD between studies, which include the WGC criteria, (15,30)the 2009 ASE criteria (20,27), and isolated parameters of diastolic function (TR, LAVI, E/e'). (22)(23)(24)(25)31)Given the high variability in the criteria employed, we could not include most of these studies in our meta-analysis.…”

“…Another study (33) compared the WCG criteria to the CCMC criteria to determine which were better at predicting post-LT MACE. Multivariable analysis showed that patients that ful lled CCMC criteria were at increased risk of developing MACE (HR, 1.93; 95% CI, 1.05-3.56; p = 0.04) after controlling for covariates.…”

The trends in cost associated with liver transplantation in the US: Analysis of weighted hospital data

“…In addition, it has been estimated that as many as 50% of patients undergoing LT are found to have some degree of cirrhotic cardiomyopathy, which is associated with a greater severity of liver disease 30. Cirrhotic cardiomyopathy could potentiate an increased risk of posttransplant cardiac complications, increasing the complexity and duration, and therefore cost of care associated with the transplant hospitalization 31,32. As waitlist times increase, patients may be more likely to develop comorbid illnesses that require multidisciplinary care coordination and contribute to increased costs related to LT hospitalization.…”

“…[30] Cirrhotic cardiomyopathy could potentiate an increased risk of posttransplant cardiac complications, increasing the complexity and duration, and therefore cost of care associated with the transplant hospitalization. [31,32] As waitlist times increase, patients may be more likely to develop comorbid illnesses that require multidisciplinary care coordination and contribute to increased costs related to LT hospitalization. This is potentially reflected in our analysis, which indicates increasing LT-related incidence and costs among patients with ≥ 2 comorbidities.…”

Cirrhotic cardiomyopathy: Toward an optimized definition

“…In this issue of Liver Transplantation , Spann et al have approached this question by comparing the definitions of CCM with clinical output in terms of MACE and cardiac function. [ 7 ] In a single‐center retrospective study, the authors included 210 of 1165 patients with pre–liver transplantation echocardiography and eligibility criteria. The authors applied MACE comprising arrythmia, heart failure, cardiac arrest, or cardiac death as primary composite endpoints.…”