Cirrhotic Cardiomyopathy in the Era of Liver Transplantation: Time for Precise Stepwise Evaluation

Abstract

Liver cirrhosis (LC) is an important cause of mortality. Access to liver transplantation (LT) has significantly improved the prognosis of LC. A rigorous pre-transplant cardiac evaluation is mandatory, since cardiac dysfunction is considered the main cause of mortality after LT. Notwithstanding, the most updated pre-LT evaluation guidelines provide only an algorithm for the evaluation of major cardiovascular diseases, with no specific recommendations concerning cirrhotic cardiomyopathy (CCM), which is linked to various complications in LC, especially the development of heart failure after invasive procedures and surgical interventions, including LT. CCM is characterized by a cardiac dysfunction that includes systolic and/or diastolic dysfunction and/or electrophysiological abnormalities, in the absence of other known cardiac diseases. The role of the novel methods, tissue Doppler imaging and speckle tracking echocardiography, might be essential in the early detection of cardiac dysfunction, with prognosis implications in LC. All these new methods were only recently included in the CCM diagnosis algorithm. This review summarizes the old and novel techniques used for the diagnosis of CCM, with their diagnosis and prognostic role. It also highlights the strengths and the weaknesses of the new provided CCM diagnostic consensus, and proposes a step-by- step novel diagnostic algorithm, in order to better detect cardiac dysfunction.cirrhotic cardiomyopathy

Cardiac risk stratification of the liver transplant candidate: A comprehensive review

“…Pretransplant evaluation: Patients with ESLD can be screened for cirrhotic cardiomyopathy through biological markers and imaging modalities, wherein they supplement data obtained from history and physical examination[ 61 ]. Imaging appears to provide maximum diagnostic value when used in the appropriate clinical context.…”

“…However, galectin-3, and soluble ST-2 are also markers for liver inflammation and fibrosis, which may limit their applicability to CCM[ 69 ]. In addition to highly sensitive C-reactive protein associated with cardiac disease (and other inflammatory conditions), other inflammatory markers have been studied in HF and CCM including IL-6, IL-8, TNF-α, lipopolysaccharide binding protein, vascular endothelial growth factor, and soluble urokinase-type plasminogen activator receptor, some of which may worsen the circulatory dysfunction of portal hypertension[ 47 , 53 , 61 , 63 ].…”

“…Systolic dysfunction is characterized by either left ventricular ejection fraction (LVEF) ≤ 50% or global longitudinal strain (GLS) < 18% even in the presence of a normal LVEF[ 47 , 53 ]. Some studies have recommended a higher a cut-off value of LVEF 55%-60% in patients with ESLD due to the decreased afterload and increased preload, which could falsely normalize the LVEF in this subset[ 61 ]. GLS is particularly useful as the longitudinally oriented subendocardial fibers are highly susceptible to damage making longitudinal left ventricular function the first manifestation of cardiac impairment[ 53 ].…”

What’s New in Cirrhotic Cardiomyopathy?—Review Article

“…Since 2005, the progress in cardiac diagnostics greatly changed the concept of ventricular dysfunction and made the criteria out of date. In 2019, a multidisciplinary group consisting of cardiologists, hepatologist, and anaesthesiologists formed the Cirrhotic Cardiomyopathy Consortium and presented novel proposed criteria of CCM [7,8]. These novel diagnostic criteria approach CCM with contemporary cardiovascular imaging parameters with an emphasis on echocardiography.…”

“…Galectin-3 is a novel biomarker associated with cardiac diastolic [8] and systolic [51] dysfunction with documented clinical application in acute and chronic heart failure [52]. A significant increase in the galectin-3 serum level was found in patients with cirrhosis and in animal models of liver cirrhosis.…”