Increased myocardial contractility identifies patients with decompensated cirrhosis requiring liver transplantation

Abstract

Late allocation of organs for transplant impairs post-liver transplantation (LT) survival. Cardiac dysfunction, especially diastolic and autonomic dysfunction, is frequent and plays an important role in the prognosis of patients with cirrhosis. However, the role of myocardial contractility is unexplored, and its prognostic value is controversially discussed. This study analyses the role of myocardial contractility assessed by speckle tracking echocardiography in LT allocation. In total, 168 patients with cirrhosis (training cohort, 111; validation cohort [VC], 57) awaiting LT in 2 centers were included in this retrospective study. Also, 51 patients from the training and all patients from the VC were transplanted, 36 patients of the training and 38 of the VC were alive at the end of follow-up, and 21 nontransplanted patients died. Contractility of the left ventricle (LV) increased with severity of the Child-Pugh score. Interestingly, higher LV contractility in the training cohort patients, especially in those with Child-Pugh C, was an independent predictor of reduced transplant-free survival. In male patients, the effects on survival of increased left and right ventricular myocardial contractility were more pronounced. Notably, competing risk analysis demonstrated that increased contractility is associated with earlier LT, which could be confirmed in the VC. Importantly, LV myocardial contractility had no impact on survival of patients not receiving LT or on post-LT survival. In conclusion, this study demonstrates for the first time that increased myocardial contractility in decompensated patients identifies patients who require LT earlier, but without increased post-LT mortality.Liver Transplantation 24 15-25 2018 AASLD.

Redefining Cirrhotic Cardiomyopathy for the Modern Era

“…Data on strain imaging to detect CCM in patients with normal LVEF are limited and conflicting, with three studies showing normal longitudinal strain (16)(17)(18) and one multicenter study showing diminished longitudinal strain in one of two cohorts of patients with cirrhosis. (19) The latter study also showed that as liver disease advances, the GLS increases and correlates with impaired transplant-free survival. A plausible explanation for this finding is that as patients with ESLD become sicker, their systemic vascular resistance decreases, resulting in decreased afterload and increased cardiac contractility.…”

“…Although a limitation of GLS is that it varies with age and sex and is affected by LV loading conditions, the 2015 ASE guidelines for chamber quantification suggest GLS as an adjunct to assess LV systolic function in patients with normal LVEF. Data on strain imaging to detect CCM in patients with normal LVEF are limited and conflicting, with three studies showing normal longitudinal strain and one multicenter study showing diminished longitudinal strain in one of two cohorts of patients with cirrhosis . The latter study also showed that as liver disease advances, the GLS increases and correlates with impaired transplant‐free survival.…”

Cardiodynamic state is associated with systemic inflammation and fatal acute‐on‐chronic liver failure

“…Moreover, echocardiography is widely available. Especially, more sophisticated techniques, such as speckle tracking echocardiography (STE), were shown to be able to predict ACLF development in patients with TIPS 31,32 . STE therefore seems to be a promising tool for non‐invasive assessment of cardiodynamics and its impact on ACLF development should be investigated in future studies.…”

Intraoperative Troponin Elevation in Liver Transplantation Is Independently Associated With Mortality: A Prospective Observational Study

“…The influence of extrahepatic comorbidities in relevant outcomes during and after LT is well recognized . However, the evaluation of cardiac abnormalities in this context is challenging due to specific cirrhosis‐related hemodynamic features and to the absence of a precise definition of cirrhotic cardiomyopathy . In cirrhotic cardiomyopathy, systolic and diastolic dysfunction may be unmasked by stressful situations, such as major surgery.…”