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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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Desai MS. Mechanistic insights into the pathophysiology of cirrhotic cardiomyopathy. Anal Biochem 2021; 636:114388. [PMID: 34587512 DOI: 10.1016/j.ab.2021.114388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/22/2021] [Accepted: 09/15/2021] [Indexed: 02/08/2023]
Abstract
Myocardial dysfunction in end stage cirrhotic liver disease, termed cirrhotic cardiomyopathy, is a long known, but little understood comorbidity seen in ∼50% of adults and children who present for liver transplantation. Structural, functional, hemodynamic and electrocardiographic aberrations that occur in the heart as a direct consequence of a damaged liver, is associated with multi-organ failure and increased mortality and morbidity in patients undergoing surgical procedures such as porto-systemic shunt placement and liver transplantation. Despite its clinical significance and rapid advances in science and pharmacotherapy, there is yet no specific treatment for this disease. This may be due to a lack of understanding of the pathogenesis and mechanisms behind how a cirrhotic liver causes cardiac pathology. This review will focus specifically on insights into the molecular mechanisms that drive this liver-heart interaction. Deeper understanding of the etio-pathogenesis of cirrhotic cardiomyopathy will allow us to design and test treatments that can be targeted to prevent and/or reverse this co-morbid consequence of liver failure and improve health care delivery and outcomes in patients with cirrhosis.
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Affiliation(s)
- Moreshwar S Desai
- Department of Pediatrics, Section of Pediatric Critical Care Medicine and Liver ICU. Baylor College of Medicine, Houston, TX, 77030, USA.
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53
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Yazdanyar A, Lo KB, Pelayo J, Sanon J, Romero A, Quintero E, Ahluwalia A, Gupta S, Sankaranarayanan R, Mathew R, Rangaswami J. Association Between Cirrhosis and 30-Day Rehospitalization After Index Hospitalization for Heart Failure. Curr Probl Cardiol 2021; 47:100993. [PMID: 34571101 DOI: 10.1016/j.cpcardiol.2021.100993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 11/18/2022]
Abstract
There are limited data on clinical outcomes in patients re-admitted with decompensated heart failure (HF) with concomitant liver cirrhosis. We conducted a cross sectional analysis of the Nationwide Readmissions Database (NRD) years 2010 thru 2012. An Index admission was defined as a hospitalization for decompensated heart failure among persons aged ≥ 18 years with an alive discharge status. The main outcome was 30 - day all-cause rehospitalization. Survey logistic regression provided the unadjusted and adjusted odds of 30 - day rehospitalization among persons with and without cirrhosis, accounting for age, gender, kidney dysfunction and other comorbidities. There were 2,147,363 heart failure (HF) hospitalizations among which 26,156 (1.2%) had comorbid cirrhosis. Patients with cirrhosis were more likely to have a diagnosis of acute kidney injury (AKI) during their index hospitalization (18.4% vs 15.2%). There were 469,111 (21.9%) patients with readmission within 30 - days. The adjusted odds of a 30 - day readmission was significantly higher among patients with cirrhosis compared to without after adjusting for comorbid conditions (adjusted Odds Ratio [aOR], 1.3; 95% Confidence Interval [CI}: 1.2 to 1.4). The relative risk of 30 - day readmission among those with cirrhosis but without renal disease (aOR, 1.3; 95% CI: 1.3 to 1.3) was lower than those with both cirrhosis and renal disease (aOR, 1.8; 95% CI: 1.6 to 2.0) when compared to persons without either comorbidities. Risk of 30 - day rehospitalization was significantly higher among patients with heart failure and underlying cirrhosis. Concurrent renal dysfunction among patients with cirrhosis hospitalized for decompensated HF was associated with a greater odds of rehospitalization.
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Affiliation(s)
- Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Jerald Pelayo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA.
| | - Julien Sanon
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA
| | - Ardel Romero
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Eduardo Quintero
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Arjan Ahluwalia
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA
| | - Shuchita Gupta
- University Advanced Heart Failure Center, University Heart and Vascular Institute, Augusta GA
| | - Rajiv Sankaranarayanan
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Roy Mathew
- Division of Nephrology, Columbia VA Health Care System, Columbia, SC, USA
| | - Janani Rangaswami
- Division of Nephrology, George Washington University School of Medicine, Washington DC, USA
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Mester RA, Stoll WD. Cirrhotic Cardiomyopathy and Cardiac Failure after Liver Transplantation: A Case Series. Transplant Proc 2021; 53:2354-2357. [PMID: 34417032 DOI: 10.1016/j.transproceed.2021.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/02/2021] [Accepted: 07/19/2021] [Indexed: 11/20/2022]
Abstract
Preoperative cardiac functional assessment has been a long-debated topic in liver transplantation. Debate continues to exist regarding the use of invasive cardiac studies, and the utility of each prior to transplant. Despite the debate, a 7% mortality can be attributed to significant cardiac events. We present a case series of 3 patients who underwent orthotopic liver transplantation and developed significant cardiac dysfunction postoperatively. All preoperative cardiac assessments in each patient were normal with no hemodynamically significant abnormalities. Interestingly enough, each patient developed cardiac failure due to completely different diagnoses.
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Affiliation(s)
- Robert A Mester
- Department of Anesthesia and Perioperative Medicine-Medical University of South Carolina, Charleston, South Carolina.
| | - W David Stoll
- Department of Anesthesia and Perioperative Medicine-Medical University of South Carolina, Charleston, South Carolina
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Not for the Faint of Heart. Ann Am Thorac Soc 2021; 18:519-523. [PMID: 33646074 DOI: 10.1513/annalsats.202007-817cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Echocardiography in the Liver Transplant Patient. Curr Cardiol Rep 2021; 23:110. [PMID: 34216273 DOI: 10.1007/s11886-021-01531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to review current echocardiographic modalities utilized in the assessment of the preoperative liver transplant candidate with an emphasis on newer techniques. We sought to assess if newer methods imparted additional diagnostic or prognostic accuracy compared to prior methods based on existing studies. RECENT FINDINGS Standard dobutamine stress echocardiography offers important information regarding operative risk and post-operative survival in liver transplant candidates; however, technologies such as speckle-tracking echocardiography (STE) and evaluation of diastolic function have emerged as useful tools as well. 2D-STE and diastolic echocardiography offer additional parameters such as global longitudinal strain and measures of diastolic dysfunction that can better predict peri-operative and post-operative complications in liver transplant candidates. If able, practitioners should utilize these methods routinely in their assessment of liver transplant candidates.
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Abstract
Cirrhotic cardiomyopathy is a critical factor that causes morbidity and mortality in crucial conditions such as liver transplantation. In animal model, the common pathophysiologic mechanisms of cirrhotic cardiomyopathy are similar to those associated with bile duct ligation (BDL). Overproduction of inflammatory and oxidant markers plays a crucial role in cirrhotic cardiomyopathy. Spermidine, a multifunctional polyamine, is known for its antioxidant and anti-inflammatory effects. In this study, we investigated the effects of spermidine on development of cirrhotic cardiomyopathy in BDL rats. Rats were randomly housed in 6 groups. Except the normal and sham groups, BDL was performed for all the control and spermidine groups. Seven days after operation, 3 different doses of spermidine (5, 10 and 50 mg/kg) were administrated until day 28, in spermidine groups. At the end of the fourth week, the electrocardiography (ECG) and papillary muscle isolation were performed. The serum level of tumor necrosis factor-a (TNF-α), interleukin-1β (IL-1β), and IL-10 and cardiac level of superoxide dismutase, glutathione (GSH). and malondialdehyde (MDA) were assessed. Furthermore, the nuclear factor-κB (NF-κB) expression was assessed by western blot. Cardiac histopathological changes were monitored. The serum levels of magnesium (Mg) and potassium (K) were investigated. Control group, exhibited exaggerated signs of cirrhotic cardiomyopathy in comparison with the sham group. Co-administration of spermidine at the dose of 10 mg/kg in BDL rats significantly improved the cardiac condition, reduced the inflammatory mediators, and increased antioxidant enzymes. In addition, the histopathologic findings were in accordance with the other results of the study. Besides, there was no significant alteration in serum levels of Mg and K. This study demonstrates that spermidine at the dose of 10 mg/kg significantly improved the cirrhotic cardiomyopathy in BDL model in rats.
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58
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Nasser I, Miranda H, Perez RDM, Cabiddu R, Malosa L, Dias I, Brown A, Reis MS. Limited cardiopulmonary capacity in patients with liver cirrhosis when compared to healthy subjects. Rev Assoc Med Bras (1992) 2021; 67:94-100. [PMID: 34161483 DOI: 10.1590/1806-9282.67.01.20200449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The present study compared cardiorespiratory capacity between cirrhotic patients and healthy subjects. METHODS Nineteen cirrhotic patients and 19 healthy subjects, paired by age and gender, participated in the study. Volunteers performed an incremental cardiopulmonary test with a ramp protocol, a ventilatory and metabolic variables were obtained and analyzed. The recovery was analyzed by calculating the time needed for 50% of oxygen consumption (VO2) recovery to occur as the median between the peak of the exercise and the end of recovery on the VO2 curve (T1/2). The VE/VCO2 slope were performed by the linear regression of ventilation (VE) and carbon dioxide production (VCO2) data. RESULTS During resting condition, cirrhotic patients presented significantly higher levels of VO2 compared to healthy subjects. The VE/ VO2 and VE/ VCO2 values were significantly higher in the control group at the anaerobic threshold and at the peak of the test compared to cirrhotic patients. Time under effort was significantly higher for healthy subjects. CONCLUSIONS Based on these findings, it is possible to conclude that liver cirrhosis can compromise the patients' quality of life, mainly by inducing metabolic alterations which can impair functional capacity and lead to a sedentary lifestyle.
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Affiliation(s)
- Igor Nasser
- Universidade Federal do Rio de Janeiro, Escola de Educação Física e Desportos - Rio de Janeiro (RJ), Brasil.,Universidade Federal do Rio de Janeiro, Laboratório de Desempenho, Treinamento e Exercício Físico - Rio de Janeiro (RJ), Brasil.,Universidade Federal do Rio de Janeiro, Grupo de Pesquisa em Avaliação e Reabilitação Cardiorrespiratória - Rio de Janeiro (RJ), Brasil
| | - Humberto Miranda
- Universidade Federal do Rio de Janeiro, Escola de Educação Física e Desportos - Rio de Janeiro (RJ), Brasil.,Universidade Federal do Rio de Janeiro, Laboratório de Desempenho, Treinamento e Exercício Físico - Rio de Janeiro (RJ), Brasil
| | - Renata de Mello Perez
- Universidade Federal do Rio de Janeiro, Serviço de Hepatologia - Rio de Janeiro (RJ), Brasil.,Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | - Ramona Cabiddu
- Universidade Federal de São Carlos, Laboratório de Fisioterapia Cardiopulmonar - São Carlos (SP), Brasil
| | - Luciana Malosa
- Universidade Nove de Julho, Pós-graduação Stricto Sensu em Ciências da Reabilitação - São Paulo (SP), Brasil
| | - Ingrid Dias
- Universidade Federal do Rio de Janeiro, Escola de Educação Física e Desportos - Rio de Janeiro (RJ), Brasil
| | - Amanda Brown
- Universidade Federal do Rio de Janeiro, Escola de Educação Física e Desportos - Rio de Janeiro (RJ), Brasil
| | - Michel Silva Reis
- Universidade Federal do Rio de Janeiro, Escola de Educação Física e Desportos - Rio de Janeiro (RJ), Brasil.,Universidade Federal do Rio de Janeiro, Serviço de Hepatologia - Rio de Janeiro (RJ), Brasil
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59
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Elfeki MA, O'Shea R, Carey WD. Randomized Trials of Interventions for Hospitalized Patients with Cirrhosis. N Engl J Med 2021; 384:e90. [PMID: 34107190 DOI: 10.1056/nejmc2105498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Cirrhotic cardiomyopathy (CCM) connotes systolic and/or diastolic dysfunction in patients with end-stage liver disease in the absence of prior heart disease. Its prevalence is variable across different studies but recent data suggest that CCM may affect up to one third of liver transplant candidates. The etiology of CCM is multifactorial. CCM defining features were recently revised to improve the diagnostic and prognostic yield of CCM criteria and inform candidate selection for liver transplantation. CCM appears to increase the risk for unfavorable outcomes pre- and post-transplant. Close clinical and echocardiographic follow-up of patients with CCM may mitigate adverse cardiac outcomes.
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Affiliation(s)
- MANHAL J IZZY
- Assistant Professor, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN
| | - LISA B VANWAGNER
- Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology,Department of Preventive Medicine, Division of Epidemiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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61
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Dourakis SP, Geladari E, Geladari C, Vallianou N. Cirrhotic Cardiomyopathy: The Interplay Between Liver and Cardiac Muscle. How Does the Cardiovascular System React When the Liver is Diseased? Curr Cardiol Rev 2021; 17:78-84. [PMID: 31072296 PMCID: PMC8142364 DOI: 10.2174/1573403x15666190509084519] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/21/2019] [Accepted: 04/22/2019] [Indexed: 12/03/2022] Open
Abstract
It is widely known that liver cirrhosis, regardless of the etiologies is accompanied by severe hemodynamic changes. The principal pathophysiological mechanisms are the hyperdynamic circulation with increased cardiac output, heart rate along with reduced systemic vascular resistance. Thus, counteractive mechanisms may develop that eventually lead to systolic as well as diastolic dysfunction and rhythm disturbances, in order to keep a steady homeostasis in the human body. Literally, blunted contractile responsiveness to physical or pharmacological stress, impaired diastolic relaxation and electrophysiological changes, primarily QT interval prolongation, do occur progressively in a cirrhotic patient with no known preexisting cardiac disease. This condition is identified as cirrhotic cardiomyopathy (CCM), an entity different from that seen in alcoholic cardiac muscle disease. For the past decades, clinicians did study and attempt to understand the pathophysiology and clinical significance of this process. Indeed, various factors have been identified acting at the molecular and cellular level. Electrocardiography, echocardiography and various serum biomarkers are the main tools that help healthcare practitioners to point to the correct diagnosis. Noteworthy, the subjects that suffer from cirrhotic cardiomyopathy may progress to heart failure during invasive procedures such as surgery, insertion of a transjugular intrahepatic portosystemic shunting (TIPS) and liver transplantation. Besides, several studies have illustrated that CCM is a contributing factor, or even a precipitant, of hepatorenal syndrome (HRS), a conceivable reversible kidney failure in patients with liver cirrhosis and ascites. The treatment is the same as it is in the patients with liver cirrhosis and heart failure and there is no particular treatment for cirrhotic cardiomyopathy. Hence, it is of utmost importance to clearly comprehend the pathophysiology of this disease in order to design more accurate diagnostic tools and definitive treatments in a way to prevent the complications of cirrhosis and overt heart failure. The objective of this review is to describe in a comprehensive way the pathological alterations that occur in the cardiovascular system of cirrhotic patients. It will also point the limitations that remain in the diagnosis and treatment strategies and more importantly, this review will alert the clinicians in the modern era to further observe and record additional pathological changes in this subset of patients.
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Affiliation(s)
- Spyros P Dourakis
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Eleni Geladari
- Internal Medicine Department, Evaggelismos General Hospital, Athens, Greece
| | | | - Natalia Vallianou
- Internal Medicine Department, Evaggelismos General Hospital, Athens, Greece
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Addoumieh A, Abdallah MS, Ballout JA, Thuita L, Klein A, Jaber WA, Arsanjani R, Carey W, Majdalany D. Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 4:100026. [PMID: 38559677 PMCID: PMC10976285 DOI: 10.1016/j.ahjo.2021.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/04/2021] [Accepted: 06/05/2021] [Indexed: 04/04/2024]
Abstract
Introduction Patients with end stage liver disease (ESLD) have a hyperdynamic state due to decreased systemic vascular resistance and increased cardiac output. Preoperative evaluation with dobutamine stress echocardiography (DSE) is used to risk-stratify patients prior to liver transplant. We sought to identify the impact of inducible left ventricular outflow tract obstruction (LVOTO) on DSE on post-operative liver transplant outcomes. Methods Patients with ESLD who underwent liver transplant at Cleveland Clinic between January 2007 and August 2016 were identified. Pre-operative DSE data, and post-operative intensive care unit (ICU) data were extracted. Patients with inducible LVOTO were compared to those without LVOTO. Results Of the 515 patients identified who underwent DSE prior to liver transplant, 165 (30%) were female, and 95 (18%) had LVOTO. There were no major differences in baseline characteristics between the two groups. In the LVOTO group, rest gradients were 10.8 ± 3 mm Hg while peak gradients were 90 ± 48.2 mm Hg. No significant differences in ICU length of stay or duration of mechanical ventilation between both groups were noted. There were 21 deaths at 30 days. There were 2 (2.1%) deaths in the LVOTO group, versus 19 (4.5%) deaths in the non LVOTO group (p = 0.28). Higher Model for End Stage Liver Disease (MELD) scores predicted longer duration of mechanical ventilation and ICU length of stay. Conclusion Inducible LVOTO on DSE does not adversely affect the short-term outcomes post liver transplant. Presence of inducible LVOTO should not be the mere reason to deny liver transplant among patients with ESLD.
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Affiliation(s)
| | | | - Jad A. Ballout
- Heart and Vascular Institute, Cleveland Clinic Foundation, USA
| | - Lucy Thuita
- Quantitative Health Science Department, Cleveland Clinic Foundation, USA
| | - Allan Klein
- Heart and Vascular Institute, Cleveland Clinic Foundation, USA
| | - Wael A. Jaber
- Heart and Vascular Institute, Cleveland Clinic Foundation, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - William Carey
- Digestive Disease Institute, Cleveland Clinic Foundation, USA
| | - David Majdalany
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
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Hepatocardiac or Cardiohepatic Interaction: From Traditional Chinese Medicine to Western Medicine. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6655335. [PMID: 33777158 PMCID: PMC7981187 DOI: 10.1155/2021/6655335] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/18/2021] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
There is a close relationship between the liver and heart based on "zang-xiang theory," "five-element theory," and "five-zang/five-viscus/five-organ correlation theory" in the theoretical system of Traditional Chinese Medicine (TCM). Moreover, with the development of molecular biology, genetics, immunology, and others, the Modern Medicine indicates the existence of the essential interorgan communication between the liver and heart (the heart and liver). Anatomically and physiologically, the liver and heart are connected with each other primarily via "blood circulation." Pathologically, liver diseases can affect the heart; for example, patients with end-stage liver disease (liver failure/cirrhosis) may develop into "cirrhotic cardiomyopathy," and nonalcoholic fatty liver disease (NAFLD) may promote the development of cardiovascular diseases via multiple molecular mechanisms. In contrast, heart diseases can affect the liver, heart failure may lead to cardiogenic hypoxic hepatitis and cardiac cirrhosis, and atrial fibrillation (AF) markedly alters the hepatic gene expression profile and induces AF-related hypercoagulation. The heart can also influence liver metabolism via certain nonsecretory cardiac gene-mediated multiple signals. Moreover, organokines are essential mediators of organ crosstalk, e.g., cardiomyokines link the heart to the liver, while hepatokines link the liver to the heart. Therefore, both TCM and Western Medicine, and both the basic research studies and the clinical practices, all indicate that there exist essential "heart-liver axes" and "liver-heart axes." To investigate the organ interactions between the liver and heart (the heart and liver) will help us broaden and deepen our understanding of the pathogenesis of both liver and heart diseases, thus improving the strategies of prevention and treatment in the future.
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von Köckritz F, Braun A, Schmuck RB, Dobrindt EM, Eurich D, Heinzel FR, Pieske B, Escher F, Zhang K. Speckle Tracking Analysis Reveals Altered Left Atrial and Ventricular Myocardial Deformation in Patients with End-Stage Liver Disease. J Clin Med 2021; 10:jcm10050897. [PMID: 33668295 PMCID: PMC7956617 DOI: 10.3390/jcm10050897] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/20/2021] [Accepted: 02/14/2021] [Indexed: 02/07/2023] Open
Abstract
Background: Cardiac function can be influenced by liver cirrhosis and should be thoroughly evaluated before liver transplantation. We investigated left ventricular (LV) and, for the first time, left atrial (LA) strain and strain rate in end-stage liver cirrhosis patients of different etiologies. Methods: This retrospective, cross-sectional study evaluated left heart function in 80 cirrhosis patients and 30 controls using standardized echocardiographic techniques and speckle tracking technology (STE) analysis. Serum markers of liver function were used for correlation analysis. Results: While conventional parameters demonstrated no alteration in systolic function, speckle tracking analysis showed a significant increase in LV longitudinal strain throughout all cardiac layers, with significant correlation to model of end-stage liver disease (MELD) score. LA reservoir and conduit strain as well as LA strain rate in all phases were significantly reduced in end-stage liver disease (ESLD) patients compared to control. STE for the evaluation of LA phasic function seemed to be more sensitive than volumetric methods. Kaplan-Meier curves showed a trend towards reduced post-transplant survival in patients with a reduced LA reservoir and conduit strain. Conclusion: STE analysis detected increased LV and decreased LA deformation in cirrhosis patients, thus proving to be highly sensitive to cardiac changes and useful for more precise cardiac evaluation.
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Affiliation(s)
- Franzisca von Köckritz
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
| | - Alexander Braun
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
| | - Rosa B. Schmuck
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (R.B.S.); (E.M.D.); (D.E.)
| | - Eva M. Dobrindt
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (R.B.S.); (E.M.D.); (D.E.)
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (R.B.S.); (E.M.D.); (D.E.)
| | - Frank R. Heinzel
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
- German Heart Center Berlin, Department of Internal Medicine and Cardiology, 13353 Berlin, Germany
| | - Felicitas Escher
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
| | - Kun Zhang
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (F.v.K.); (A.B.); (F.R.H.); (B.P.); (F.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450659746
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The interplay between gastrointestinal and cardiovascular diseases: a narrative review focusing on the clinical perspective. Eur J Gastroenterol Hepatol 2021; 32:132-139. [PMID: 32516176 DOI: 10.1097/meg.0000000000001779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Both cardiovascular and gastrointestinal disorders represent considerable health burden on community clinics and hospitals with overwhelming economic cost. An overlap in the occurrence of these disorders is encountered in daily practice. Both affect each other in bidirectional manner through several mechanisms including altered hemodynamics, systemic inflammation, bacterial overgrowth and interactions and adverse effects of medications. In addition, to the known overlap in the symptoms occurrence of upper gastrointestinal tract diseases and cardiovascular diseases (CVDs). Awareness of this interplay and its clinical manifestations optimizes patient management, and could prevent catastrophic consequences and even save lives. In this review, we highlighted the clinical aspects of this bidirectional association between gastrointestinal and CVDs aiming to shed light on this topic and improve patients' care.
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66
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Wang F, So KF, Xiao J, Wang H. Organ-organ communication: The liver's perspective. Am J Cancer Res 2021; 11:3317-3330. [PMID: 33537089 PMCID: PMC7847667 DOI: 10.7150/thno.55795] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/28/2020] [Indexed: 12/11/2022] Open
Abstract
Communication between organs participates in most physiological and pathological events. Owing to the importance of precise coordination among the liver and virtually all organs in the body for the maintenance of homeostasis, many hepatic disorders originate from impaired organ-organ communication, resulting in concomitant pathological phenotypes of distant organs. Hepatokines are proteins that are predominantly secreted from the liver, and many hepatokines and several signaling proteins have been linked to diseases of other organs, such as the heart, muscle, bone, and eyes. Although liver-centered interorgan communication has been proposed in both basic and clinical studies, to date, the regulatory mechanisms of hepatokine production, secretion, and reciprocation with signaling factors from other organs are obscure. Whether other hormones and cytokines are involved in such communication also warrants investigation. Herein, we summarize the current knowledge of organ-organ communication phenotypes in a variety of diseases and the possible involvement of hepatokines and/or other important signaling factors. This provides novel insight into the underlying roles and mechanisms of liver-originated signal transduction and, more importantly, the understanding of disease in an integrative view.
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Chung HS, Woo AM, Chae MS, Hong SH, Park CS, Choi JH, Jo YS. Combined B-type Natriuretic Peptide as strong predictor of short-term mortality in patients after Liver Transplantation. Int J Med Sci 2021; 18:2500-2509. [PMID: 34104081 PMCID: PMC8176164 DOI: 10.7150/ijms.54202] [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: 10/08/2020] [Accepted: 04/14/2021] [Indexed: 12/07/2022] Open
Abstract
Background: B-type natriuretic peptide (BNP) is a well-known predictor for prognosis in patients with cardiac and renal diseases. However, there is a lack of studies in patients with advanced hepatic disease, especially patients who underwent liver transplantation (LT). We evaluated whether BNP could predict the prognosis of patients who underwent LT. Material and Methods: The data from a total of 187 patients who underwent LT were collected retrospectively. The serum levels of BNP were acquired at four time points, the pre-anhepatic (T1), anhepatic (T2), and neohepatic phases (T3), and on postoperative day 1 (T4). The patients were dichotomized into survival and non-survival groups for 1-month mortality after LT. Combined BNP (cBNP) was calculated based on conditional logistic regression analysis of pairwise serum BNP measurements at two time points, T2 and T4. The area under the receiver operating characteristic curve (AUROC) was analyzed to determine the diagnostic accuracy and cut-off value of the predictive models, including cBNP. Results: Fourteen patients (7.5 %) expired within one month after LT. The leading cause of death was sepsis (N = 9, 64.3 %). The MELD and MELD-Na scores had an acceptable predictive ability for 1-month mortality (AUROC = 0.714, and 0.690, respectively). The BNPs at each time point (T1 - T4) showed excellent predictive ability (AUROC = 0.864, 0.962, 0.913, and 0.963, respectively). The cBNP value had an outstanding predictive ability for 1-month mortality after LT (AUROC = 0.976). The optimal cutoff values for cBNP at T2 and T4 were 137 and 187, respectively. Conclusions: The cBNP model showed the improved predictive ability for mortality within 1-month of LT. It could help clinicians stratify mortality risk and be a useful biomarker in patients undergoing LT.
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Affiliation(s)
- Hyun Sik Chung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - AMi Woo
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Ho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yun Sung Jo
- Department of Obstetrics and Gynecology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Gyeonggi, Republic of Korea
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Chelakkat M, Jacob M, Sebastian S, Paul G, NM A, Joy B, Afsal M. Echocardiographic abnormalities in patients with chronic liver disease: Observations from Thrissur, Kerala, India. MGM JOURNAL OF MEDICAL SCIENCES 2021. [DOI: 10.4103/mgmj.mgmj_84_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Durst MM, Eitzen EA, Benken ST. Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis. Ann Pharmacother 2020; 55:970-979. [PMID: 33327736 DOI: 10.1177/1060028020980727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients with cirrhosis have immune dysfunction, altered inflammatory response, and hemodynamic changes which increase risk of septic shock and potentially prolong management with fluids, vasopressors, and other therapies. Due to limited available guidance, this study aimed to characterize vasopressor use in patients with cirrhosis in relation to patients without cirrhosis in septic shock. METHODS This was a retrospective matched cohort analysis of 122 patients admitted to the intensive care unit (ICU) at an academic medical center from January 2015 to November 2017. Patients were grouped based on the presence or absence of cirrhosis and matched based on severity of illness scoring. The primary outcome was vasopressor duration. Secondary comparisons included total vasopressor requirement, length of hospital and ICU stay, in-hospital mortality, change in organ function, and discharge disposition. RESULTS The group with cirrhosis had significantly longer median (interquartile range [IQR]) durations of vasopressor therapy compared with the group without cirrhosis (86.0 [42.0-164.5] vs 39.0 [14.5-82.0] hours; P = 0.003) leading to increased median (IQR) vasopressor exposure (71.7 [15.5-239.5] vs 24.7 [5.3-77.9] mg norepinephrine [NE] equivalents; P = 0.003). No difference was found in in-hospital mortality between groups. However, regression analysis showed vasopressor exposure was associated with in-hospital mortality. CONCLUSION AND RELEVANCE Patients with cirrhosis in septic shock have increased vasopressor durations and overall requirements compared with patients without cirrhosis. Increased durations and requirements is associated with poorer outcomes independent of presence of cirrhosis. Future studies are needed to improve vasopressor treatment strategies and end points utilized in cirrhosis.
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70
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Nasser I, Perez RDM, Reis MS, Dias I, Willardson JM, Miranda H. Cardiovascular Acute Effects of Traditional vs. Paired Set Resistance Training in Patients With Liver Cirrhosis. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2020; 91:630-639. [PMID: 31999503 DOI: 10.1080/02701367.2019.1696013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/14/2019] [Indexed: 06/10/2023]
Abstract
Purpose: This study compared the acute effects of two different resistance training methods on heart rate variability, blood pressure, and rating of perceived exertion in patients with liver cirrhosis. Methods: Ten patients with Child-Pugh A (seven women and three men) participated in two experimental sessions, in random order: The traditional set condition consisted of three sets of six exercises performed in a sequential manner, while the paired set condition consisted of alternating sets between two exercises (three pairs of exercises). Ten repetitions were performed for each set with 70% of a 10 repetition maximum load and with 2 min rest between sets. Blood pressure and heart rate variability were assessed pre-workout and for 60 min post-workout. The rating of perceived exertion was assessed at the end of the third set for each exercise. Results: Significant alterations in heart rate variability were observed when considering the lowest value obtained during recovery, in which the SDNN was reduced in both the traditional set and paired set conditions, as well as the root mean square of standard deviation for the traditional set condition (p < .05). Additionally, for the paired set condition, there was a significant reduction in the HFnu band and a significant increase in the LFnu band (p < .05). Effect size showed reductions in diastolic and mean blood pressure until 30 min in a small magnitude for traditional sets. Conclusion: Similar cardiovascular responses were observed between methods eliciting normal physiological responses within safe limits for patients with liver cirrhosis.
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71
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Cirrhotic Cardiomyopathy - A Veiled Threat. Cardiol Rev 2020; 30:80-89. [PMID: 33229904 DOI: 10.1097/crd.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.
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72
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Zardi EM, Giorgi C, Dobrina A, Vecile E, Zardi DM. Analogies and differences between cirrhotic cardiomyopathy and hepatopulmonary syndrome. Med Res Rev 2020; 41:739-753. [PMID: 33174630 DOI: 10.1002/med.21755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
Cirrhotic cardiomyopathy and hepatopulmonary syndrome are two quite frequent clinical entities that may complicate the course of liver cirrhosis. The common pathophysiological origin and the same clinical presentation make them difficult to compare. Cirrhotic cardiomyopathy and hepatopulmonary syndrome may start with dyspnea and breathlessness but the former is characterized by a chronic cardiac dysfunction and the latter by a defect of oxygenation due to pulmonary shunts formation. The focus is to differentiate them as soon as possible since the treatment is different until the patient undergoes liver transplant that is the real unique cure for them.
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Affiliation(s)
- Enrico Maria Zardi
- Internistic Ultrasound Service, Campus Bio-Medico University, Rome, Italy
| | - Chiara Giorgi
- Department of Radiology, S. Maria Della Misericordia Hospital, Urbino, Italy
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Elena Vecile
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Domenico Maria Zardi
- Interventional Cardiology Department of S. Andrea Hospital, University "La Sapienza", Rome, Italy
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Honar H, Liu H, Zhang ML, Glenn TK, Ter Keurs HEDJ, Lee SS. Impaired myosin isoform shift and calcium transients contribute to cellular pathogenesis of rat cirrhotic cardiomyopathy. Liver Int 2020; 40:2808-2819. [PMID: 32654385 DOI: 10.1111/liv.14599] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/28/2020] [Accepted: 07/04/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Cirrhotic cardiomyopathy is a recently recognized entity, but detailed cellular and molecular mechanisms remain unclarified. We aimed to elucidate the role of myosin heavy chain isoform shifts and their relation to calcium transients in the contractile kinetics of cirrhotic rats. METHODS Cirrhosis was induced in male Lewis Brown-Norway rats by bile duct ligation (BDL). Myosin heavy chain (MHC) isoform distribution was evaluated by gel electrophoresis. Contractile force, Ca2+ transients and cell shortening were studied at varied frequency and extracellular [Ca2+ ]. T-tubular integrity was analysed by power spectrum analysis of images of myocytes stained with di-8-ANEPPS. RESULTS Compared with sham controls, the phenotypes of cirrhotic rats were as follows: (a) alpha-myosin heavy chain shifted to beta-MHC isoform; (b) mild loss of T-tubular integrity in myocytes; (c) a reduced maximum and rate of rise of the Ca2+ transient (max F/Fo ); (d) a reduction in both the rate of rise and fall of contraction; (e) decreased maximal force-generating capacity; (f) loss of the inotropic effect of increased stimulus frequency; (g) unchanged sensitivity of force development to varied extracellular [Ca2+ ] and (h) increased spontaneous diastolic sarcomere length fluctuations. CONCLUSION Cardiomyocytes and ventricular trabeculae in a cirrhotic rat model showed features of typical heart failure including systolic and diastolic prolongation, impaired force-frequency relation and decreased force-generating capacity. Impaired myosin isoform shift and calcium transients are important contributory mechanisms underlying the pathogenesis of the heart failure phenotype seen in cirrhosis.
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Affiliation(s)
- Hooman Honar
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Mei L Zhang
- Department of Cardiac Sciences of the Libin Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Tamara K Glenn
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Henk E D J Ter Keurs
- Department of Cardiac Sciences of the Libin Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Kapoor N, Mehta V, Singh B, Karna R, Kumar S, Kar P. Prevalence of cirrhotic cardiomyopathy and its relationship with serum pro-brain natriuretic peptide, hepatorenal syndrome, spontaneous bacterial peritonitis, and mortality. Indian J Gastroenterol 2020; 39:481-486. [PMID: 33188455 DOI: 10.1007/s12664-020-01083-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study aims at estimating the prevalence of cirrhotic cardiomyopathy in a cohort of cirrhosis patients in northern India using the World Congress of Gastroenterology 2005 criteria and its relationship with grades of cirrhosis, its complications, and all-cause mortality. METHODS This was a prospective study in which 53 cirrhosis patients underwent the 2D color Doppler, and tissue Doppler echocardiography. Echocardiography findings were compared with thirty age- and sex-matched healthy controls. Additionally, serum pro-brain natriuretic peptide (pro-BNP) and troponin-T levels were measured. Patients were followed up for 6 months to look for complications and mortality. RESULT 2D echocardiography findings revealed that diastolic cardiomyopathy with no gross systolic dysfunction was significantly prevalent in cirrhosis patients. Using the Montreal criteria, we found the incidence of diastolic cardiomyopathy to be 56.6%. Tissue Doppler echocardiography findings were also correlated. Diastolic dysfunction correlated with the severity of cirrhosis, and patients with higher Child score had more diastolic dysfunction. Serum pro-BNP levels and QTc interval were also higher in patients with diastolic dysfunction. On survival analysis, patients with cirrhotic cardiomyopathy had shorter survival and greater frequency of encephalopathy and hepatorenal syndrome (HRS) episodes as compared with cirrhotic patients without cardiomyopathy, though the differences were not statistically significant. CONCLUSION The study showed that diastolic dysfunction was highly prevalent (56.6% of the study population) in cirrhosis patients. QTc interval and pro-BNP were also significantly raised. Also, complications of cirrhosis like HRS, spontaneous bacterial peritonitis, and hepatic encephalopathy were more common in the cirrhotic cardiomyopathy group.
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Affiliation(s)
- N Kapoor
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - V Mehta
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - B Singh
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - R Karna
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - S Kumar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - P Kar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India.
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Chen JL, Chen YL, Qi B, Pan ZY, Lu YF, Zhang W, Zhu J, Yu WF, Song JC, Lu YG. Impact of Intraoperative Norepinephrine Support on Living Donor Liver Transplantation Outcomes: A Retrospective Cohort Study of 430 Children. Front Pharmacol 2020; 11:1254. [PMID: 32922292 PMCID: PMC7456957 DOI: 10.3389/fphar.2020.01254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
Norepinephrine (NE) is often administered during the perioperative period of liver transplantation to address hemodynamic instability and to improve organ perfusion and oxygen supply. However, its role and safety profile have yet to be evaluated in pediatric living donor liver transplantation (LDLT). We hypothesized that intraoperative NE infusion might affect pediatric LDLT outcomes. A retrospective study of 430 pediatric patients (median [interquartile range] age, 7 [6.10] months; 189 [43.9%] female) receiving LDLT between 2014 and 2016 at Renji Hospital was conducted. We evaluated patient survival among recipients who received intraoperative NE infusion (NE group, 85 recipients) and those that did not (non-NE group, 345 recipients). The number of children aged over 24 months and weighing more than 10 kg in NE group was more than that in non-NE group. And children in NE group had longer operative time, longer anhepatic phase time and more fluid infusion. After multivariate regression analysis and propensity score regression adjusting for confounding factors to determine the influence of intraoperative NE infusion on patient survival, the NE group had a 169% more probability of dying. Although there was no difference in mean arterial pressure changes relative to the baseline between the two groups, we did observe increased heart rates in NE group compared with those of the non-NE group at anhepatic phase (P=0.025), neohepatic phase (P=0.012) and operation end phase (P=0.017) of the operation. In conclusion, intraoperative NE infusion was associated with a poorer prognosis for pediatric LDLT recipients. Therefore, we recommend the application of NE during pediatric LDLT should be carefully re-considered.
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Affiliation(s)
- Jiang-Long Chen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of General Surgery, Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan-Li Chen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bo Qi
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Ying Pan
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ye-Feng Lu
- Department of Hepatic Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Zhang
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Jiao Zhu
- Department of Anesthesiology, Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Wei-Feng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin-Chao Song
- Department of Anesthesiology, Shidong Hospital of Shanghai, University of Shanghai for Science and Technology, Shanghai, China
| | - Yu-Gang Lu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Mousavi K, Niknahad H, Ghalamfarsa A, Mohammadi H, Azarpira N, Ommati MM, Heidari R. Taurine mitigates cirrhosis-associated heart injury through mitochondrial-dependent and antioxidative mechanisms. Clin Exp Hepatol 2020; 6:207-219. [PMID: 33145427 PMCID: PMC7592093 DOI: 10.5114/ceh.2020.99513] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022] Open
Abstract
Cirrhosis-induced heart injury and cardiomyopathy is a serious consequence of this disease. It has been shown that bile duct ligated (BDL) animals could serve as an appropriate experimental model to investigate heart tissue injury in cirrhosis. The accumulation of cytotoxic chemicals (e.g., bile acids) could also adversely affect the heart tissue. Oxidative stress and mitochondrial impairment are the most prominent mechanisms of bile acid cytotoxicity. Taurine (Tau) is the most abundant non-protein amino acid in the human body. The cardioprotective effects of this amino acid have repeatedly been investigated. In the current study, it was examined whether mitochondrial dysfunction and oxidative stress are involved in the pathogenesis of cirrhosis-induced heart injury. Rats underwent BDL surgery. BDL animals received Tau (50, 100, and 500 mg/kg, i.p.) for 42 consecutive days. A significant increase in oxidative stress biomarkers was detected in the heart tissue of BDL animals. Moreover, it was found that heart tissue mitochondrial indices of functionality were deteriorated in the BDL group. Tau treatment significantly decreased oxidative stress and improved mitochondrial function in the heart tissue of cirrhotic animals. These data provide clues for the involvement of mitochondrial impairment and oxidative stress in the pathogenesis of heart injury in BDL rats. On the other hand, Tau supplementation could serve as an effective ancillary treatment against BDL-associated heart injury. Mitochondrial regulating and antioxidative properties of Tau might play a fundamental role in its mechanism of protective effects in the heart tissue of BDL animals.
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Affiliation(s)
- Khadijeh Mousavi
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Niknahad
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Ghalamfarsa
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamidreza Mohammadi
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Azarpira
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Sawalha K, Kadado AJ, Gupta K, Al-Akchar M, Battisha A, Abozenah M, Salerno C, Gupta M, Khan A, Islam AM. Outcomes of MitraClip Placement in Patients With Liver Cirrhosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 29:50-53. [PMID: 32839129 DOI: 10.1016/j.carrev.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Liver cirrhosis is associated with increased morbidity and mortality. Many preoperative risk assessment tools do not take into account the presence or degree of liver cirrhosis prior to surgery. Over recent years, percutaneous mitral valve repair using MitraClip has emerged as an option for patients at high risk of surgical intervention. However, the safety, efficacy and outcomes of this procedure in patients with liver cirrhosis have not yet been evaluated. METHODS This is a retrospective cohort study using the 2013-2017 National Inpatient Sample database of adults who were hospitalized for MitraClip repair of mitral valve. All patients were divided into patients with cirrhosis and those without cirrhosis. The primary outcome was all-cause mortality in patient with cirrhosis who underwent MitraClip. The secondary outcomes were to assess length of stay (LOS) and total hospital cost per year in cirrhotic patients compared to non-cirrhotic patients. RESULTS In-hospital mortality was higher in cirrhosis group compared to non-cirrhosis however not statistically significant (8.1% vs 3.2%, OR: 2.59 [95% CI: 0.47-14.28, p-value 0.27). Additionally, neither of the secondary outcomes, LOS and total cost, were found to be statistically significant. However, the incidence of cardiogenic shock was significantly higher in the cirrhosis group 13.3% versus 3.9% (p-value 0.032). CONCLUSION Patients with liver cirrhosis who underwent MitraClip repair of MV were at higher risk of developing cardiogenic shock, without any significant increase in in-hospital mortality, LOS or total cost. However, this study showed a trend toward higher rates of mortality, requirement of blood transfusion, mechanical ventilation, length of stay, and cost of care in cirrhosis patients.
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Affiliation(s)
- Khalid Sawalha
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America; Department of Public Health Practice, School of Public Health and Health Sciences, University of New England, Biddeford, ME, United States of America.
| | - Anis John Kadado
- Department of Cardiology, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Kamesh Gupta
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Mohammad Al-Akchar
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Ayman Battisha
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Mohammed Abozenah
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Colby Salerno
- Department of Internal Medicine, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
| | - Manish Gupta
- Department of Internal Medicine, Danbury Hospital, CT, United States of America
| | - Ahmad Khan
- Department of Internal Medicine, West Virginia University, Charleston, WV, United States of America
| | - Ashequl M Islam
- Department of Cardiology, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America
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Isaak A, Praktiknjo M, Jansen C, Faron A, Sprinkart AM, Pieper CC, Chang J, Fimmers R, Meyer C, Dabir D, Thomas D, Trebicka J, Attenberger U, Kuetting D, Luetkens JA. Myocardial Fibrosis and Inflammation in Liver Cirrhosis: MRI Study of the Liver-Heart Axis. Radiology 2020; 297:51-61. [PMID: 32808886 DOI: 10.1148/radiol.2020201057] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Cardiac involvement in liver cirrhosis in the absence of underlying cardiac disease is termed cirrhotic cardiomyopathy. The pathophysiology of this condition is still poorly understood. Purpose To investigate the extent of subclinical imaging changes in terms of fibrosis and inflammation and to explore the relationship between the severity of liver disease and the degree of myocardial involvement. Materials and Methods In this prospective study from November 2018 to December 2019, participants with liver cirrhosis and healthy control participants underwent hepatic and cardiac MRI. The multiparametric scan protocol assessed hepatic (T1 and T2 relaxation times, extracellular volume [ECV], and MR elastography-based liver stiffness) and cardiac (T1 and T2 relaxation times, ECV, myocardial edema, late gadolinium enhancement [LGE], and myocardial strain) parameters. Student t tests, one-way analysis of variance, Pearson correlation, and multivariable binary regression analysis were used for statistical analyses. Results A total of 42 participants with liver cirrhosis (mean age ± standard deviation, 57 years ± 11; 23 men) and 18 control participants (mean age, 54 years ± 19; 11 men) were evaluated. Compared with control participants, the participants with liver cirrhosis displayed reduced longitudinal strain and elevated markers of myocardial disease (T1 and T2 relaxation times, ECV, and qualitative and quantitative LGE). Myocardial T1 (978 msec ± 23 vs 1006 msec ± 29 vs 1044 msec ± 14; P < .001) and T2 relaxation times (56 msec ± 4 vs 59 msec ± 3 vs 62 msec ± 8; P = .04) and ECV (30% ± 5 vs 33% ± 5 vs 38% ± 7; P = .009) were higher depending on Child-Pugh class (A vs B vs C). Positive LGE lesions (three of 11 [27%] vs 10 of 19 [53%] vs nine of 11 [82%]; P = .04) were more prevalent in advanced Child-Pugh classes. MR elastography-based liver stiffness was an independent predictor for LGE (odds ratio, 1.6; 95% confidence interval: 1.2%, 2.1%; P = .004) and correlated with quantitative LGE (r = 0.67; P < .001), myocardial T1 relaxation times (r = 0.55; P < .001), and ECV (r = 0.39; P = .01). Conclusion In participants with liver cirrhosis, systolic dysfunction and elevated parameters of myocardial edema and fibrosis were observed at MRI, which were more abnormal with greater severity of liver disease. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by de Roos and Lamb in this issue.
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Affiliation(s)
- Alexander Isaak
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Michael Praktiknjo
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Christian Jansen
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Anton Faron
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Alois M Sprinkart
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Claus C Pieper
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Johannes Chang
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Rolf Fimmers
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Carsten Meyer
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Darius Dabir
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Daniel Thomas
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Jonel Trebicka
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Ulrike Attenberger
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Daniel Kuetting
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
| | - Julian A Luetkens
- From the Departments of Radiology (A.I., A.F., A.M.S., C.C.P., C.M., D.D., D.T., U.A., D.K., J.A.L.) and Internal Medicine I (M.P., C.J., J.C.), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; Quantitative Imaging Laboratory Bonn (QILaB), Bonn, Germany (A.I., A.F., A.M.S., D.D., D.T., D.K., J.A.L.); Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany (R.F.); Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany (J.T.)
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Arya S, Deshpande H, Belwal S, Sharma P, Sadana P, Chandrakant, Rahman F, Gupta M, Uniyal B. Association between cardiac dysfunction, arrhythmias and chronic liver diseases: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kim HM, Kim HK, Lee JH, Lee YB, Park EA, Park JB, Lee SP, Kim YJ, Kim YJ, Yoon JH, Sohn DW. Myocardial structural and functional changes in patients with liver cirrhosis awaiting liver transplantation: a comprehensive cardiovascular magnetic resonance and echocardiographic study. J Cardiovasc Magn Reson 2020; 22:25. [PMID: 32321533 PMCID: PMC7178724 DOI: 10.1186/s12968-020-00622-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 03/31/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cardiac dysfunction is increasingly recognized in patients with liver cirrhosis. Nevertheless, the presence or absence of structural alterations such as diffuse myocardial fibrosis remains unclear. We aimed to investigate myocardial structural changes in cirrhosis, and explore left ventricular (LV) structural and functional changes induced by liver transplantation. METHODS This study included 33 cirrhosis patients listed for transplantation and 20 healthy controls. Patients underwent speckle-tracking echocardiography and cardiovascular magnetic resonance (CMR) with extracellular volume fraction (ECV) quantification at baseline (n = 33) and 1 year after transplantation (n = 19). RESULTS CMR-based LV ejection fraction (CMRLV-EF) and echocardiographic LV global longitudinal strain (LV-GLS) demonstrated hyper-contractile LV in cirrhosis patients (CMRLV-EF: 67.8 ± 6.9% in cirrhosis vs 63.4 ± 6.4% in healthy controls, P = 0.027; echocardiographic GLS: - 24.2 ± 2.7% in cirrhosis vs - 18.6 ± 2.2% in healthy controls, P < 0.001). No significant differences in LV size, wall thickness, mass index, and diastolic function between cirrhosis patients and healthy controls were seen (all P > 0.1). Only one of the cirrhosis patients showed late gadolinium enhancement. However, cirrhosis patients showed a higher ECV (31.6 ± 5.1% vs 25.4 ± 1.9%, P < 0.001) than healthy controls. ECV showed a positive correlation with Child-Pugh score (r = 0.564, P = 0.001). Electrocardiogram-based corrected QT interval was prolonged in cirrhosis (P < 0.001). One-year post-transplantation, echocardiographic LV-GLS (from - 24.9 ± 2.4% to - 20.6 ± 3.4%, P < 0.001) and ECV (from 30.9 ± 4.5% to 25.4 ± 2.6%, P = 0.001) moved to the normal ranges. Corrected QT interval decreased after transplantation (from 475 ± 41 to 429 ± 30 msec, P = 0.001). CONCLUSIONS Myocardial extracellular volume expansion with augmented resting LV systolic function was characteristic of cirrhotic cardiomyopathy, which normalizes 1-year post-transplantation. Thus, myocardial extracellular expansion represents a structural component of myocardial changes in cirrhosis.
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Affiliation(s)
- Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Section of Cardiovascular Imaging, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Section of Cardiovascular Imaging, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Jeong-Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Yun Bin Lee
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Eun-Ah Park
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Section of Cardiovascular Imaging, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Seung-Pyo Lee
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Section of Cardiovascular Imaging, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Yoon Jun Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Yong-Jin Kim
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Section of Cardiovascular Imaging, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Jung-Hwan Yoon
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Dae-Won Sohn
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Section of Cardiovascular Imaging, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
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Matyas C, Erdelyi K, Trojnar E, Zhao S, Varga ZV, Paloczi J, Mukhopadhyay P, Nemeth BT, Haskó G, Cinar R, Rodrigues RM, Ahmed YA, Gao B, Pacher P. Interplay of Liver-Heart Inflammatory Axis and Cannabinoid 2 Receptor Signaling in an Experimental Model of Hepatic Cardiomyopathy. Hepatology 2020; 71:1391-1407. [PMID: 31469200 PMCID: PMC7048661 DOI: 10.1002/hep.30916] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Hepatic cardiomyopathy, a special type of heart failure, develops in up to 50% of patients with cirrhosis and is a major determinant of survival. However, there is no reliable model of hepatic cardiomyopathy in mice. We aimed to characterize the detailed hemodynamics of mice with bile duct ligation (BDL)-induced liver fibrosis, by monitoring echocardiography and intracardiac pressure-volume relationships and myocardial structural alterations. Treatment of mice with a selective cannabinoid-2 receptor (CB2 -R) agonist, known to attenuate inflammation and fibrosis, was used to explore the impact of liver inflammation and fibrosis on cardiac function. APPROACH AND RESULTS BDL induced massive inflammation (increased leukocyte infiltration, inflammatory cytokines, and chemokines), oxidative stress, microvascular dysfunction, and fibrosis in the liver. These pathological changes were accompanied by impaired diastolic, systolic, and macrovascular functions; cardiac inflammation (increased macrophage inflammatory protein 1, interleukin-1, P-selectin, cluster of differentiation 45-positive cells); and oxidative stress (increased malondialdehyde, 3-nitrotyrosine, and nicotinamide adenine dinucleotide phosphate oxidases). CB2 -R up-regulation was observed in both livers and hearts of mice exposed to BDL. CB2 -R activation markedly improved hepatic inflammation, impaired microcirculation, and fibrosis. CB2 -R activation also decreased serum tumor necrosis factor-alpha levels and improved cardiac dysfunction, myocardial inflammation, and oxidative stress, underlining the importance of inflammatory mediators in the pathology of hepatic cardiomyopathy. CONCLUSIONS We propose BDL-induced cardiomyopathy in mice as a model for hepatic/cirrhotic cardiomyopathy. This cardiomyopathy, similar to cirrhotic cardiomyopathy in humans, is characterized by systemic hypotension and impaired macrovascular and microvascular function accompanied by both systolic and diastolic dysfunction. Our results indicate that the liver-heart inflammatory axis has a pivotal pathophysiological role in the development of hepatic cardiomyopathy. Thus, controlling liver and/or myocardial inflammation (e.g., with selective CB2 -R agonists) may delay or prevent the development of cardiomyopathy in severe liver disease.
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Affiliation(s)
- Csaba Matyas
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Katalin Erdelyi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Eszter Trojnar
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Suxian Zhao
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Zoltan V. Varga
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA,ZVV’s present affiliation: HCEMM-SU Cardiometabolic Immunology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Janos Paloczi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Partha Mukhopadhyay
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Balazs T. Nemeth
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - György Haskó
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
| | - Resat Cinar
- Laboratory of Physiologic Studies, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Robim M. Rodrigues
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Yeni Ait Ahmed
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Bin Gao
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD, USA
| | - Pal Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD, USA
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Impact of cardiac function, refractory ascites and beta blockers on the outcome of patients with cirrhosis listed for liver transplantation. J Hepatol 2020; 72:463-471. [PMID: 31622697 DOI: 10.1016/j.jhep.2019.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/27/2019] [Accepted: 10/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs. METHODS This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis. RESULTS LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1 g-m/m2. In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p = 0.0083) and treatment by NSBBs with LVSWI <64.1 g-m/m2 (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p = 0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score. CONCLUSIONS This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhotic patients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis. LAY SUMMARY There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhotic patients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.
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Kim SY, Kim KH, Schilling JM, Leem J, Dhanani M, Head BP, Roth DM, Zemljic-Harpf AE, Patel HH. Protective role of cardiac-specific overexpression of caveolin-3 in cirrhotic cardiomyopathy. Am J Physiol Gastrointest Liver Physiol 2020; 318:G531-G541. [PMID: 31961720 PMCID: PMC7099497 DOI: 10.1152/ajpgi.00346.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cirrhotic cardiomyopathy is a clinical syndrome in patients with liver cirrhosis characterized by blunted cardiac contractile responses to stress and/or heart rate-corrected QT (QTc) interval prolongation. Caveolin-3 (Cav-3) plays a critical role in cardiac protection and is an emerging therapeutic target for heart disease. We investigated the protective role of cardiac-specific overexpression (OE) of Cav-3 in cirrhotic cardiomyopathy. Biliary fibrosis was induced in male Cav-3 OE mice and transgene negative (TGneg) littermates by feeding a diet containing 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC; 0.1%) for 3 wk. Liver pathology and blood chemistries were assessed, and stress echocardiography, telemetry, and isolated heart perfusion studies to assess adrenergic responsiveness were performed. Cav-3 OE mice showed a similar degree of hyperdynamic contractility, pulmonary hypertension, and QTc interval prolongation as TGneg mice after 3 wk of DDC diet. Blunted systolic responses were shown in both DDC-fed Cav-3 OE and TGneg hearts after in vivo isoproterenol challenge. However, QTc interval prolongation after in vivo isoproterenol challenge was significantly less in DDC-fed Cav-3 OE hearts compared with DDC-fed TGneg hearts. In ex vivo perfused hearts, where circulatory factors are absent, isoproterenol challenge showed hearts from DDC-fed Cav-3 OE mice had better cardiac contractility and relaxation compared with DDC-fed TGneg hearts. Although Cav-3 OE in the heart did not prevent cardiac alterations in DDC-induced biliary fibrosis, cardiac expression of Cav-3 reduced QTc interval prolongation after adrenergic stimulation in cirrhosis.NEW & NOTEWORTHY Prevalence of cirrhotic cardiomyopathy is up to 50% in cirrhotic patients, and liver transplantation is the only treatment. However, cirrhotic cardiomyopathy is associated with perioperative morbidity and mortality after liver transplantation; therefore, management of cirrhotic cardiomyopathy is crucial for successful liver transplantation. This study shows cardiac myocyte specific overexpression of caveolin-3 (Cav-3) provides better cardiac contractile responses and less corrected QT prolongation during adrenergic stress in a cirrhotic cardiomyopathy model, suggesting beneficial effects of Cav-3 expression in cirrhotic cardiomyopathy.
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Affiliation(s)
- So Yeon Kim
- 1Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kang Ho Kim
- 2Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas
| | - Jan M. Schilling
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
| | - Joseph Leem
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
| | - Mehul Dhanani
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
| | - Brian P. Head
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
| | - David M. Roth
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
| | - Alice E. Zemljic-Harpf
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
| | - Hemal H. Patel
- 3Veterans Administration San Diego Healthcare System and the Department of Anesthesiology, University of California, San Diego, School of Medicine, San Diego, California
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Toma L, Stanciu AM, Zgura A, Bacalbasa N, Diaconu C, Iliescu L. Electrocardiographic Changes in Liver Cirrhosis-Clues for Cirrhotic Cardiomyopathy. ACTA ACUST UNITED AC 2020; 56:medicina56020068. [PMID: 32050594 PMCID: PMC7073951 DOI: 10.3390/medicina56020068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.
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Affiliation(s)
- Letitia Toma
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Adriana Mercan Stanciu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
| | - Anca Zgura
- Chemotherapy Department, OncoFort Hospital, 022328 Bucharest, Romania;
| | - Nicolae Bacalbasa
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Camelia Diaconu
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 022328 Bucharest, Romania;
| | - Laura Iliescu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Correspondence: ; Tel.: +407-22-235-695
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Effect of direct-acting antivirals on corrected QT interval and cardiac functions in patients with chronic hepatitis C virus infection. Egypt Heart J 2020; 72:7. [PMID: 32030482 PMCID: PMC7005241 DOI: 10.1186/s43044-020-0042-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background Hepatitis C virus (HCV) infection is a major public health problem in Egypt. The use of direct-acting antivirals (DAAs) in such patients has been shown to be highly effective. The cardiac safety of such antivirals remains uncertain. This study aimed to assess the effect of the novel DAAs on corrected QT (QTc) interval and on cardiac function using trans-thoracic echocardiography. Results This was a prospective cohort study performed on 100 patients suffering from chronic HCV infection. Patients were into two equal groups according to the presence of liver cirrhosis. The group without liver cirrhosis received a daily combination of sofosbuvir 400 mg and daclatasvir 60 mg for 12 weeks while that with liver cirrhosis (Child-Pugh score A or B) received a daily combination of sofosbuvir 400 mg, daclatasvir 60 mg, and ribavirin 600 mg for 12 weeks. Surface ECG and trans-thoracic echocardiography were performed prior to the start of treatment and after 12 weeks of treatment. At the end of treatment, no changes were observed in QTc interval in those with (p = 0.48) or without (p = 0.048) liver cirrhosis. In patients without liver cirrhosis, right ventricular global longitudinal strain (RV GLS) decreased from 22 (−30 to −17) to −21 (−27–18), p = 0.024. In patients with liver cirrhosis, lateral mitral E’ velocity was reduced from 14.38 ± 3.59 to 13.62 ± 3.21 cm/s, p = 0.02 and indexed left atrial volume (LAVI) was increased from 25.96 ± 3.96 to 26.86 ± 4.12 ml/m2, p = 0.032. There were no changes in both groups regarding left ventricular (LV) dimensions, ejection fraction, trans-mitral E/A ratio, E/E’ ratio, deceleration time, right ventricular (RV) systolic pressure, mean pulmonary artery pressure, RV fractional area change, tricuspid annular plane systolic excursion, and LV GLS. Conclusion The current national protocol of HCV infection treatment with direct-acting antiviral agents used in Egyptian patients has a good cardiac safety profile. Such treatments have no effect on QTc interval, left and right ventricular functions except for a decrease in RV GLS in those with no liver cirrhosis and a reduction in lateral mitral E’ velocity in those with liver cirrhosis both remained within the normal reference range.
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The Challenges With the Cardiac Evaluation of Liver and Kidney Transplant Candidates. Transplantation 2020; 104:251-258. [DOI: 10.1097/tp.0000000000002951] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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89
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Dercle L, Ma J, Xie C, Chen AP, Wang D, Luk L, Revel-Mouroz P, Otal P, Peron JM, Rousseau H, Lu L, Schwartz LH, Mokrane FZ, Zhao B. Using a single abdominal computed tomography image to differentiate five contrast-enhancement phases: A machine-learning algorithm for radiomics-based precision medicine. Eur J Radiol 2020; 125:108850. [PMID: 32070870 DOI: 10.1016/j.ejrad.2020.108850] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/25/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The clinical adoption of quantitative imaging biomarkers (radiomics) has established the need for high quality contrast-enhancement in medical images. We aimed to develop a machine-learning algorithm for Quality Control of Contrast-Enhancement on CT-scan (CECT-QC). METHOD Multicenter data from four independent cohorts [A, B, C, D] of patients with measurable liver lesions were analyzed retrospectively (patients:time-points; 503:3397): [A] dynamic CTs from primary liver cancer (60:2359); [B] triphasic CTs from primary liver cancer (31:93); [C] triphasic CTs from hepatocellular carcinoma (121:363); [D] portal venous phase CTs of liver metastasis from colorectal cancer (291:582). Patients from cohort A were randomized to training-set (48:1884) and test-set (12:475). A random forest classifier was trained and tested to identify five contrast-enhancement phases. The input was the mean intensity of the abdominal aorta and the portal vein measured on a single abdominal CT scan image at a single time-point. The output to be predicted was: non-contrast [NCP], early-arterial [E-AP], optimal-arterial [O-AP], optimal-portal [O-PVP], and late-portal [L-PVP]. Clinical utility was assessed in cohorts B, C, and D. RESULTS The CECT-QC algorithm showed performances of 98 %, 90 %, and 84 % for predicting NCP, O-AP, and O-PVP, respectively. O-PVP was reached in half of patients and was associated with a peak in liver malignancy density. Contrast-enhancement quality significantly influenced radiomics features deciphering the phenotype of liver neoplasms. CONCLUSIONS A single CT-image can be used to differentiate five contrast-enhancement phases for radiomics-based precision medicine in the most common liver neoplasms occurring in patients with or without liver cirrhosis.
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Affiliation(s)
- Laurent Dercle
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA.
| | - Jingchen Ma
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA
| | - Chuanmiao Xie
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, China
| | - Ai-Ping Chen
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA
| | - Deling Wang
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, China
| | - Lyndon Luk
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA
| | - Paul Revel-Mouroz
- Radiology Department, Rangueil University Hospital, Toulouse, France
| | - Philippe Otal
- Radiology Department, Rangueil University Hospital, Toulouse, France
| | - Jean-Marie Peron
- Hepatology Department, Purpan University Hospital, Toulouse, France
| | - Hervé Rousseau
- Radiology Department, Rangueil University Hospital, Toulouse, France
| | - Lin Lu
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA
| | - Lawrence H Schwartz
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA
| | - Fatima-Zohra Mokrane
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA; Radiology Department, Rangueil University Hospital, Toulouse, France
| | - Binsheng Zhao
- Columbia University Vagellos College of Physicians and Surgeons, Department of Radiology, New York, New York City, USA; Department of Radiology New York Presbyterian Hospital, USA
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Arya S, Kumar P, Tiwari B, Belwal S, Saxena S, Abbas H. What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review. Indian J Crit Care Med 2020; 24:1251-1255. [PMID: 33446981 PMCID: PMC7775933 DOI: 10.5005/jp-journals-10071-23695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objectives Impairment of cardiac function and arrhythmias often coexist in patients with liver diseases. Many studies have proved this coexistence and put forward various theories toward its pathophysiology. This narrative review tries to find the answers with supporting evidence on five main questions: Materials and methods Clinical evidence was obtained by using search engines, namely, Cochrane Library, PubMed, and Google Scholar. Studies published in journals in the English language, between January 1969 and December 2019, which mentioned the relationship between cardiac arrhythmia and liver disease, were included. We used the keywords: jaundice, bilirubin, arrhythmia, ECG, QTc interval, QT dispersion, liver, and cirrhosis. Relevant animal or human studies answering the five main questions were extracted and reviewed. Conclusion The evidence included in our review sheds light on the fact that approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy (CC) and there has been an association between liver abnormalities and cardiac pathology. The present review also supports that there exists a strong association between high levels of serum bilirubin levels and cardiac arrhythmias, QTc value can be relied upon as a risk factor for predicting imminent arrhythmias, and that it is associated with mortality. Its basic pathophysiology can be explained by the potential action of bile acids in prolonging the QT interval. It also causes cardiac hypertrophy and apoptosis of cardiomyocytes leading to cardiac dysfunction. How to cite this article Arya S, Kumar P, Tiwari B, Belwal S, Saxena S, Abbas H. What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review. Indian J Crit Care Med 2020;24(12):1251–1255.
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Affiliation(s)
- Sanjeev Arya
- Department of Critical Care, Max Super Specialty Hospital (Previously), Dehradun, India
| | - Prashant Kumar
- Department of Critical Care, Kailash Hospital, Noida, Uttar Pradesh, India
| | - Bhuwan Tiwari
- Department of Cardiology, Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India
| | - Shantanu Belwal
- Department of Critical Care, Max Super Specialty Hospital, Dehradun, India
| | - Sanjay Saxena
- Department of Critical Care, Max Super Specialty Hospital, Dehradun, India
| | - Haider Abbas
- Department of ER and Critical Care, King Georges Medical University, Lucknow, Uttar Pradesh, India
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Porter T, Shillcutt S, Adams M, Desjardins G, Glas K, Olson J, Troughton R. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: A report from the american society of echocardiography. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2020. [DOI: 10.4103/2543-1463.282192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, Turco L, Dragoni G, Laffi G, Marra F. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 2020; 15:37-48. [PMID: 31919780 DOI: 10.1007/s11739-019-02252-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/03/2019] [Indexed: 12/16/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.
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Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Filippo Schepis
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Laura Turco
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Gabriele Dragoni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Giacomo Laffi
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.
- Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy.
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Billey C, Billet S, Robic MA, Cognet T, Guillaume M, Vinel JP, Péron JM, Lairez O, Bureau C. A Prospective Study Identifying Predictive Factors of Cardiac Decompensation After Transjugular Intrahepatic Portosystemic Shunt: The Toulouse Algorithm. Hepatology 2019; 70:1928-1941. [PMID: 31512743 DOI: 10.1002/hep.30934] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is now a standard for the treatment of portal hypertension-related complications. After the TIPS procedure, incidence and risk factors of cardiac decompensation are poorly known. The main objectives were to measure the incidence of the onset of cardiac decompensation after TIPS and identify the predictive factors. APPROACH AND RESULTS All patients with cirrhosis treated with TIPS between May 2011 and June 2016 were considered for inclusion. They received a cardiac assessment by standard biological parameters, transthoracic echocardiography, and right heart catheterization. Patients were followed for 1 year after TIPS insertion. The main endpoint was the incidence of cardiac decompensation requiring hospitalization. One hundred seventy-four patients were treated by TIPS during the period. One hundred patients who underwent a complete cardiac evaluation were included. A cardiac decompensation occurred in 20% of the patients. The parameters associated with the occurrence of severe cardiac decompensation were a prolonged QT interval corrected (462 vs. 443 ms; P = 0.05), an elevated pre-TIPS brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP) level, an elevated E/A ratio (1.5 vs. 1.0; P = 0.001) and E/e' ratio (11 vs. 7; P < 0.001), and a left atrial dilatation (40 vs. 29 mL/m2 ; P = 0.011). The presence of aortic stenosis was also associated with cardiac decompensation. A level of BNP <40 pg/mL and NT-proBNP <125 pg/mL allowed identifying patients without risk of cardiac decompensation. Additionally, absence of diastolic dysfunction criteria at echocardiography ruled out the risk of further cardiac decompensation. CONCLUSIONS Hospitalization for cardiac decompensation is observed in 20% of patients in the year after TIPS insertion. Combining BNP or NT-proBNP levels and echocardiographic parameters should help improve patient selection.
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Affiliation(s)
- Chloé Billey
- Liver Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Sophie Billet
- Cardiology Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Marie Angèle Robic
- Liver Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Thomas Cognet
- Cardiology Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Maeva Guillaume
- Liver Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Jean Pierre Vinel
- Liver Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Jean Marie Péron
- Liver Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Olivier Lairez
- Cardiology Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
| | - Christophe Bureau
- Liver Unit Toulouse Hospital, Paul Sabatier Universitary and Cardiomet Institute, Toulouse, France
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Abuelkasem E, Wang DW, Omer MA, Abdelmoneim SS, Howard-Quijano K, Rakesh H, Subramaniam K. Perioperative clinical utility of myocardial deformation imaging: a narrative review. Br J Anaesth 2019; 123:408-420. [DOI: 10.1016/j.bja.2019.04.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/09/2019] [Accepted: 04/28/2019] [Indexed: 01/25/2023] Open
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Kovalic AJ, Cholankeril G, Satapathy SK. Nonalcoholic fatty liver disease and alcoholic liver disease: metabolic diseases with systemic manifestations. Transl Gastroenterol Hepatol 2019; 4:65. [PMID: 31620647 DOI: 10.21037/tgh.2019.08.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
The progression of liver disease is portrayed by several common, overarching signs and symptoms. Classically, these include findings such as spider angiomata, jaundice, palmar erythema, and as cirrhosis decompensates, ascites, variceal hemorrhage (VH), hepatic encephalopathy (HE), and hepatocellular carcinoma (HCC). Aside from these universal hallmarks among cirrhotics, patients with nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) harbor their own distinct systemic associations and manifestations. NAFLD is tightly linked to metabolic syndrome, which appears to be a driving force for a multitude of comorbidities, such as insulin resistance, cardiovascular disease, chronic kidney disease (CKD), obstructive sleep apnea (OSA), as well as increased malignancy risk. ALD also maintains a variety of comorbidities congruent with systemic effects of chronic alcohol use. These findings are highlighted by cardiovascular conditions, neuronal damage, myopathy, nutritional deficiencies, chronic pancreatitis, in addition to increased malignancy risk. While a general, guideline-driven management for all cirrhotic patients remains imperative for minimizing risk of complications, a tailored treatment strategy is useful for patients with NAFLD and ALD who entertain their own constellation of unique systemic manifestations.
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Affiliation(s)
- Alexander J Kovalic
- Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, USA
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanjaya K Satapathy
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Barbara and Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, NY, USA
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96
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Predictors, burden and impact of cardiac arrhythmias among patients hospitalized with end-stage liver disease. Heart Lung 2019; 49:73-79. [PMID: 31320178 DOI: 10.1016/j.hrtlng.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD). OBJECTIVES Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes. METHODS We selected ESLD records from the Nationwide Inpatient Sample (2007-2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4). RESULTS Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures. CONCLUSIONS Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.
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97
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Vora RS, Subramanian RM. Hypotension in Cirrhosis. Clin Liver Dis (Hoboken) 2019; 13:149-153. [PMID: 31316760 PMCID: PMC6605738 DOI: 10.1002/cld.764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/22/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ravi S. Vora
- Division of Digestive DiseasesEmory School of MedicineAtlantaGA
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98
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Sakr AE, Fraser GE, Doctorian TP, Kim HB, Narasimha D, Abudayyeh I, Hilliard AD, Shih W, de Vera ME, Baron PW, Volk ML, Stoletniy LN. Predictors of Systolic Heart Failure and Mortality Following Orthotopic Liver Transplantation: a Single-Center Cohort. Transplant Proc 2019; 51:1950-1955. [DOI: 10.1016/j.transproceed.2019.04.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/05/2019] [Indexed: 12/17/2022]
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99
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Couperus L, Vliegen H, Sorgdrager B, den Dulk A, Beeres S, Sarton E, Dubbeld J, Schalij M, Jukema J, van Hoek B, Scherptong R. Prognostic Importance of Increased Right Ventricular Afterload in Orthotopic Liver Transplantation Recipients With Endstage Cirrhosis. Heart Lung Circ 2019; 28:893-900. [DOI: 10.1016/j.hlc.2018.04.290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/13/2018] [Accepted: 04/22/2018] [Indexed: 02/06/2023]
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100
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Abstract
Liver diseases frequently coexist with heart disease. The causes of coexistent heart and liver disease are categorized into four groups: (1) heart disease affecting the liver, (2) liver disease affecting the heart, (3) cardiac and hepatic manifestations of a common cause, and (4) coexistent heart and liver disease with distinct causes. Discerning the cause of cardiac and liver dysfunction is important in the management of these conditions, particularly when considering surgical intervention or heart or liver transplantation.
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Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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