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Mihailovici AR, Donoiu I, Gheonea DI, Mirea O, Târtea GC, Buşe M, Calborean V, Obleagă C, Pădureanu V, Istrătoaie O. NT-proBNP and Echocardiographic Parameters in Liver Cirrhosis - Correlations with Disease Severity. Med Princ Pract 2019; 28:000499930. [PMID: 30995644 PMCID: PMC6771067 DOI: 10.1159/000499930] [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: 10/02/2018] [Accepted: 03/27/2019] [Indexed: 11/19/2022] Open
Abstract
determined. Liver disease severity in patients with cirrhosis was established by Child-Pugh class, MELD score and presence/absence of ascites. Results: Plasma levels of NT-proBNP were significantly higher in cirrhotic patients than in the healthy subjects. NT-proBNP levels were also significantly elevated in Child-Pugh class C patients compared to those in class B and A. Left atrium size, diastolic function, left ventricular wall thickness and left ventricular ejection fraction were significantly altered in cirrhotic patients compared to controls. Advanced cirrhosis and high levels of NT-proBNP were significantly associated with increased left atrium volume and signs of cardiac diastolic dysfunction. We also observed significant differences between quartile groups of MELD score for the following: NT-proBNP, Troponin I, left atrium volume, left ventricle wall thickness, lateral wall and septum systolic tissue doppler velocities and global longitudinal strain. Conclusion: NT-proBNP is increased in patients with cirrhosis and is correlated with the severity of liver disease as established by Child-Pugh class, MELD score and presence of ascites.
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Affiliation(s)
| | - Ionuț Donoiu
- Department of Cardiology, University of Medicine and Pharmacy, Craiova, Romania
| | - Dan Ionuț Gheonea
- Research Center of Gastroenterology and Hepatology, Craiova, Romania
| | - Oana Mirea
- Department of Cardiology, University of Medicine and Pharmacy, Craiova, Romania
| | | | - Maria Buşe
- Department of Cardiology, Emergency County Hospital, Craiova, Romania
| | | | - Cosmin Obleagă
- Department of Surgery, University of Medicine and Pharmacy, Craiova, Romania
| | - Vlad Pădureanu
- Department of Internal Medicine, University of Medicine and Pharmacy, Craiova, Romania
| | - Octavian Istrătoaie
- Department of Cardiology, University of Medicine and Pharmacy, Craiova, Romania
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In HCV-related liver cirrhosis, local pulse wave velocity increases and in decompensated patients correlates with poorer survival. PLoS One 2019; 14:e0212770. [PMID: 30889181 PMCID: PMC6424395 DOI: 10.1371/journal.pone.0212770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 02/08/2019] [Indexed: 12/15/2022] Open
Abstract
Background Cirrhotic cardiomyopathy (CCM) refers to cardiac dysfunction in patients with liver cirrhosis, in the absence of other known cardiac disease. Methods Control group and patients diagnosed of liver cirrhosis without known cardiac disease or hepatocellular carcinoma were enrolled for this clinical observation study. Patients with diabetes mellitus, hypertension were excluded. Absolute global longitudinal strain, one-point carotid pulse wave velocity (one-point PWV) and various parameters were measured in resting status. Results There were 29 participants in the control group and 80 patients in the liver cirrhosis group. 27.8% of cirrhotic patients presented with normal systolic but abnormal diastolic functions and QTc prolongation that were compatible with CCM. 34.2% of cirrhotic patients presented with diastolic dysfunction in resting state comparing to 24.1% in control group. Systolic functions did not show conspicuous difference between cirrhosis and control group nor between compensated and decompensated cirrhosis, neither. Furthermore, one-point PWV was significantly higher in liver cirrhosis than in control group and higher in CCM than in non-CCM patients. One-point PWV predicted CCM and diastolic dysfunction in cirrhosis. Most importantly, its value > 1370cm/s predicted overall mortalities in decompensated cirrhosis (multivariable Cox analysis OR = 6.941) in addition to CTP score specifically in HCV related cirrhotic patients (AUC = 0.817). Conclusions In patients with cirrhosis, 27.8% were diagnosed with CCM by resting cardiovascular parameters. One-point PWV increased in CCM, correlated with diastolic dysfunction. It also correlated with overall mortality in patients with hepatitis C virus (HCV) related decompensated cirrhosis. Further study may be needed to confirm its capability for assessing CV and mortality risks in HCV related decompensated cirrhotic patients.
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103
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Carvalho MVH, Kroll PC, Kroll RTM, Carvalho VN. Cirrhotic cardiomyopathy: the liver affects the heart. ACTA ACUST UNITED AC 2019; 52:e7809. [PMID: 30785477 PMCID: PMC6376321 DOI: 10.1590/1414-431x20187809] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
Abstract
Cirrhotic cardiomyopathy historically has been confused as alcoholic cardiomyopathy. The key points for diagnosis of cirrhotic cardiomyopathy have been well explained, however this entity was neglected for a long time. Nowadays the diagnosis of this entity has become important because it is a factor that contributes significantly to morbidity-mortality in cirrhotic patients. Characteristics of cirrhotic cardiomyopathy are a hyperdynamic circulatory state, altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, particularity QT interval prolongation. The pathogenesis includes impaired function of beta-receptors, altered transmembrane currents and overproduction of cardiodepressant factors, such as nitric oxide, cytokines and endogenous cannabinoids. In addition to physical signs of hyperdynamic state and heart failure under stress conditions, the diagnosis can be done with dosage of serum markers, electrocardiography, echocardiography and magnetic resonance. The treatment is mainly supportive, but orthotopic liver transplantation appears to improve this condition although the prognosis of liver transplantation in patients with cirrhotic cardiomyopathy is uncertain.
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Affiliation(s)
- M V H Carvalho
- Departamento de Cirurgia, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - P C Kroll
- Hospital de Transplante E.J. Zerbini, São Paulo, SP, Brasil
| | - R T M Kroll
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - V N Carvalho
- Hospital Municipal Dr. Mario Gatti, Campinas, SP, Brasil
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Prediction of all-cause mortality after liver transplantation using left ventricular systolic and diastolic function assessment. PLoS One 2019; 14:e0209100. [PMID: 30682022 PMCID: PMC6347358 DOI: 10.1371/journal.pone.0209100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/28/2018] [Indexed: 01/09/2023] Open
Abstract
Although pretransplant cardiac dysfunction is considered a major predictor of poor outcomes after liver transplantation (LT), the ability of left ventricular (LV) systolic/diastolic function (LVSF/LVDF), together or individually, to predict mortality after LT is poorly characterized. We retrospectively evaluated pretransplant clinical and Doppler echocardiographic data of 839 consecutive LT recipients from 2009 to 2012 aged 18–60 years. The primary endpoint was all-cause mortality at 4 years. The overall survival rate was 91.2%. In multivariate Cox analysis, reduced LV ejection fraction (LVEF, P = 0.014) and decreased transmitral E/A ratio(P = 0.022) remained significant prognosticators. In LVSF analysis, patients with LVEF≤60% (quartile [Q]1) had higher mortality than those with LVEF>60% (hazard ratio = 1.90, 95% confidence interval = 1.15–3.15, P = 0.012). In LVDF analysis, patients with an E/A ratio<0.9(Q1) had a 2.19-fold higher risk of death (95% confidence interval = 1.11–4.32, P = 0.024) than those with an E/A ratio>1.4(Q4). In combined LVDF and LVSF analysis, patients with an E/A ratio<0.9 and LVEF≤60% had poorer survival outcomes than patients with an E/A ratio≥0.9 and LVEF>60% (79.5% versus 93.3%, P = 0.001). Patients with an early mitral inflow velocity/annular velocity (E/e’ ratio)>11.5(Q4) and LV stroke volume index (LVSVI)<33mL/m2(Q1) showed worse survival than those with an E/e’ ratio≤11.5 and LVSVI ≥33mL/m2(78.4% versus 92.2%, P = 0.003). A combination of LVSF and LVDF is a better predictor of survival than LVSF or LVDF alone.
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105
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Sharma S, Prasad A, Karamchandani K. Extracorporeal Membrane Oxygenation in a Patient With Cirrhotic Cardiomyopathy: A Case Report. J Cardiothorac Vasc Anesth 2019; 33:173-175. [DOI: 10.1053/j.jvca.2018.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Indexed: 01/16/2023]
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Lee YB, Lee JH. Cirrhotic cardiomyopathy: An independent prognostic factor for cirrhotic patients. Clin Mol Hepatol 2018; 24:372-373. [PMID: 30531663 PMCID: PMC6313017 DOI: 10.3350/cmh.2018.0098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/03/2018] [Indexed: 01/25/2023] Open
Affiliation(s)
- Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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107
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Yap EML, Supe MGS, Yu II. Cardiac Profile of Filipino Patients With Liver Cirrhosis: A 10-Year Study. Cardiol Res 2018; 9:358-363. [PMID: 30627286 PMCID: PMC6306121 DOI: 10.14740/cr804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cardiac complications among patients with liver cirrhosis have not yet been described among Filipinos. Cirrhotic cardiomyopathy is a rarely described complication that has not been extensively described in literature. This is the first study to describe the electrocardiographic and echocardiographic findings of Filipino patients with liver cirrhosis. METHODS A retrospective analytical study of 148 patients with liver cirrhosis from 2007 to 2016 at the Philippine Heart Center was done. The clinical characteristics, median QTc interval, systolic and diastolic functions on echocardiography of these patients were described. Spearman rho correlation was employed to determine the rank order correlation between QTc prolongation and the severity of liver cirrhosis. Fisher's Exact test was used to test the association of the echocardiographic parameters with the severity of liver cirrhosis. RESULTS The 10-year prevalence rate of liver cirrhosis at the Philippine Heart Center was 0.001% (148/137,584). The mean age was 72.4 ± 14 years with a female/male ratio of 1.1:1. The most common etiology of cirrhosis was hepatitis B or C infection (20%, 29). The Child-Pugh Classification (CPC) and Model for End-Stage Liver Disease (MELD) score were used to determine the severity of liver cirrhosis and to assess their prognosis. There were 31 patients (24%) with CPC-A, 84 patients (64%) with CPC-B and 15 patients (11%) with CPC-C. Fifty-five percent (n = 69) had a MELD score of 16 and below. Prolongation of the QTc interval was only seen among those with CPC A (median QTc of 470 ms) and a MELD score of 9 and below (median QTc of 485 ms). The mean left ventricular ejection fraction was 54.40±28.63%. There were five patients with a left ventricular ejection fraction of < 55%. The mean cardiac output (6.04 ± 5.24 L/min/m2) and cardiac index (2.92 ± 1.47 L/min/m2) were normal. There were 44 patients who had evidence of diastolic dysfunction based on an E/A ratio < 1, prolongation of isovolumic relaxation time (IVRT) of > 80 ms and prolongation of deceleration time (DT) of > 200 ms. There were only five patients who fulfilled the criteria for cirrhotic cardiomyopathy. A majority of the patients were discharged improved (82%). There were 26 cases who expired (18%). CONCLUSION A higher mean age of Filipinos with liver cirrhosis was reported in our study. Prolongation of the QTc interval was seen among those with early and late stage of cirrhosis (CPC A or MELD score ≤ 9 and CPC C). Most of these patients had normal left ventricular systolic function precluding the presence of cirrhotic cardiomyopathy.
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Affiliation(s)
- Emily Mae L. Yap
- Department of Adult Cardiology, Philippine Heart Center, Quezon City, Philippines
| | - Myla Gloria S. Supe
- Department of Adult Cardiology, Philippine Heart Center, Quezon City, Philippines
| | - Ira I. Yu
- Gastroenterology Unit, Department of Allied Medical Sciences, Philippine Heart Center, Quezon City, Philippines
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Park J, Lee SH, Kim J, Park SJ, Park MS, Choi GS, Lee SK, Kim GS. Predictive Value of Intraoperative Pulmonary Vascular Resistance in Liver Transplantation. Liver Transpl 2018; 24:1680-1689. [PMID: 30240130 DOI: 10.1002/lt.25341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/04/2018] [Indexed: 01/13/2023]
Abstract
We aimed to evaluate the association between intraoperative pulmonary vascular resistance (PVR) and clinical outcome of liver transplantation (LT). Cardiovascular involvement of end-stage liver disease is relatively common, and hemodynamic instability during LT can be fatal to recipients. However, the clinical impact of intraoperative PVR in LT remains undetermined. A total of 363 adult recipients with intraoperative right heart catheterization from January 2011 to May 2016 were analyzed. Patients were divided into 2 groups according to PVR. Two separate analyses were performed according to the time point of measurement: at the beginning and at the end of LT. The primary outcome was all-cause death or graft failure during the follow-up period. Increased PVR was observed in 11.8% (43/363) of recipients at the beginning and 12.7% (46/363) of recipients at the end of LT. PVR at the beginning of LT had no significant effect on the rate of death or graft failure in the multivariate analysis (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.64-2.38; P = 0.52). In contrast, PVR at the end of LT was significantly associated with death or graft failure during the overall follow-up period (HR, 2.00; 95% CI, 1.13-3.54; P = 0.02). In conclusion, PVR at the end of LT, rather than the beginning, is associated with clinical outcome. Larger trials are needed to support this finding.
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Affiliation(s)
- Jungchan Park
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeayoun Kim
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo Jung Park
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Myung Soo Park
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk-Koo Lee
- Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gaab Soo Kim
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, South Korea
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109
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Spleno-hepatic index to predict portal hypertension by equilibrium radionuclide ventriculography. Nucl Med Commun 2018; 39:1138-1142. [PMID: 30371604 DOI: 10.1097/mnm.0000000000000927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Structural and morphological changes accompanying liver cirrhosis lead to portal hypertension (PHT), which is the first step of most of the complications in patients with liver cirrhosis. Therefore, the development of noninvasive techniques to detect PHT is crucial for prognosis and treatment. AIM The aim of our study was to assess the diagnostic performance of a new spleno-hepatic index (SHI) measured from equilibrium radionuclide ventriculography (ERV) images in detecting patients with cirrhotic PHT. METHODS AND RESULTS A total of 38 patients with PHT were compared with 30 controls without liver disease. The SHI was measured on the sum of the tomographic images from the ERV and calculated according to the following formula: SHI=(mean splenic count×longest hepatic length)/mean hepatic count. Mean SHI was 54±14 and 36±8 (P<0.001) among patients with PHT and controls, respectively. A cutoff value of 40 for the SHI allowed a sensitivity of 90% and specificity of 77% to detect PHT. SHI greater than 51 was 100% specific. In a subset of 25 patients, SHI was not correlated with hepatic venous pressure gradient measured invasively in the right hepatic vein (R=-0.08, P=0.70). CONCLUSION Quantification of SHI derived from ERV could be used to detect liver cirrhosis with PHT although it is not linearly correlated with the hepatic venous pressure gradient. SHI should be considered as a useful index for the identification of PHT in patients referred for the detection/exploration of cirrhotic cardiomyopathy by ERV.
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110
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Incidence, Predictors, and Outcomes of New-Onset Left Ventricular Systolic Dysfunction After Orthotopic Liver Transplantation. J Card Fail 2018; 25:166-172. [PMID: 30412734 DOI: 10.1016/j.cardfail.2018.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/27/2018] [Accepted: 10/31/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adverse cardiovascular events after liver transplantation (LT) are relatively common and are a significant source of early mortality. Although new-onset systolic dysfunction after LT is a reported phenomenon, there is little data regarding its incidence, risk factors, and outcomes. METHODS AND RESULTS This single-center retrospective study included all adult patients from January 2002 to March 2015 with deceased-donor LT and available preoperative transthoracic echocardiograms (TTEs). In total, 1,760 patients were included in the study, 602 (34.2%) of whom had a postoperative TTE. The primary end point was development of new-onset cardiomyopathy, defined as a new left ventricular ejection fraction (LVEF) of <40% within 180days of transplant. Sixty-nine (11.4%) of the patients who received post-LT TTE had a reduction in LVEF to <40% within 6 months. Clinical parameters of donor and recipient did not show significant impact on development of post-LT LV systolic dysfunction (LVSD). Presence of wall motion abnormalities (P = .004) on preoperative TTE was predictive of development of post-LT LVSD. These patients did not have longer hospitalizations, but they had worse survival. CONCLUSIONS Post-LT LV systolic dysfunction occurs at higher rates than previously suspected and may develop more frequently in patients with underlying cardiac structural abnormalities, which appear to adversely affect post-LT survival.
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111
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Izzy M, Oh J, Watt KD. Cirrhotic Cardiomyopathy After Transplantation: Neither the Transient Nor Innocent Bystander. Hepatology 2018; 68:2008-2015. [PMID: 29672903 DOI: 10.1002/hep.30040] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/27/2018] [Accepted: 04/16/2018] [Indexed: 12/24/2022]
Abstract
Cirrhotic cardiomyopathy in end-stage liver disease is currently characterized by blunted contractile systolic response to stress with or without diastolic dysfunction in the absence of known heart disease. Since the establishment of the diagnostic criteria of cirrhotic cardiomyopathy in 2005, there have been multiple studies regarding its pathophysiology and pretransplant clinical course. The data regarding the post-transplant course of this entity are sparse. This review addresses the course and prognosis of the elements of cirrhotic cardiomyopathy after liver transplantation (LT). To this end, there is limited compelling evidence demonstrating the reversibility of this entity post-LT. Cirrhotic cardiomyopathy may, in fact, increase the risk of post-transplant complications. This review reveals a need to refine the diagnostic criteria of cirrhotic cardiomyopathy in view of the remarkable progress in the sphere of echocardiographic evaluation of systolic and diastolic dysfunction. The post-transplant course and outcomes related to cirrhotic cardiomyopathy may be better evaluated in the setting of updated diagnostic criteria.
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Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Jae Oh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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112
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Hulo S, Edme JL, Inamo J, Van Bulck R, Dharancy S, Neviere R. Elevated alveolar nitric oxide is linked to poor aerobic capacity and chronotropic incompetence in liver transplant candidates. J Breath Res 2018; 12:046008. [PMID: 30080156 DOI: 10.1088/1752-7163/aad847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND & AIMS Increased nitric oxide is involved in abnormal hemodynamic parameters and respiratory function of cirrhotic patients. We aimed to quantify partitioning exhaled nitric oxide measurements in exhaled air in liver transplantation (LT) candidates and evaluate their relationships with chronotropic incompetence and aerobic capacity. METHODS We compared exhaled nitric oxide (NO) measurements, heart rate response and peak oxygen uptake during incremental exercise in liver transplantation candidates to those of controls. RESULTS As opposed to healthy control subjects, LT candidates displayed elevated alveolar NO, blunted chronotropic response and reduced V'O2 at maximal exercise. In LT candidates, median peak V'O2 was 18.7 ml kg-1 min-1 (interquartile range (IQR) 16.2; 21.8), corresponding to 65% (IQR 57; 72) of the predicted value. Compared with controls, LT candidates had increased levels of alveolar NO (median (IQR) 2.0 (1.2; 2.2) versus 3.1 (2.3; 4.5), p < 0.001). In controls, no relations were found between alveolar NO and V'O2 peak or heart rate reserve whereas in cirrhotic patients, negative correlations and negative slopes were found between alveolar NO and V'O2 peak and heart rate reserve decrease. CONCLUSIONS Increasing alveolar NO could be a specific pathophysiological condition limiting aerobic capacity in LT candidates.
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Affiliation(s)
- S Hulo
- Service d'Explorations Fonctionnelles Respiratoires, Hôpital Calmette, CHU Lille, F-59000, France. Univ. Lille IMPECS IMPact de l'Environnement Chimique sur la Santé humaine, F-59000 Lille, France
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113
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Abstract
INTRODUCTION Liver transplantation has emerged as a successful therapy for end-stage liver disease. However, cardiovascular mortality is the leading cause of fatality in the postoperative period. The aim of this study was to reveal the prevalence and identify risk factors of early cardiovascular events (CVEs). METHODS We performed a retrospective study of all consecutive patients who underwent a primary liver transplantation from 1986 to 2017 (n = 916). We investigated the occurrence of in-hospital CVEs, their predictors, and short- and long-term outcome. RESULTS The prevalence of CVEs was 11%. The adjusted analysis showed that higher age (OR 1.06, 95% CI 1.03-1.09), higher MELD score (OR 1.04, 95% CI 1.01-1.07 CI) and sinus tachycardia at time of screening (OR 3.12, 95% CI 1.45-6.72) were positive predictors for a CVE. Preoperative propranolol use showed a trend towards a higher risk of CVE (OR 1.66, 95% CI 1.00-2.77, p = 0.051). In a sub-analysis of patients where echocardiography data were available (n = 597), a larger left atrial diameter and a higher E/E' ratio were related to early CVEs. Ten-year survival in 30-day survivors was favourable (68.6%; 56.0% vs. 69.8% in the CVE+ vs. the CVE-group, respectively, p = 0.056). DISCUSSION In conclusion, besides known risk factors (age and MELD score), sinus tachycardia (related to the presence of acute liver failure and cirrhosis) was an independent predictor for CVE after liver transplantation.
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114
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Abstract
BACKGROUND Cirrhotic cardiomyopathy is characterized by an attenuated contractile response to stress. Long-term exposure of β-adrenergic receptors to persistently high levels of catecholamines has been implicated in its pathogenesis. We hypothesized that β-blockade with metoprolol could reverse the changes in heart function and morphology in cirrhotic cardiomyopathy. PATIENTS AND METHODS In this prospective randomized trial, we included 78 patients aged between 18 and 60 years with abnormal cardiac output response under dobutamine stress echocardiography, without primary cardiac disease or a history of alcohol intake. Patients were assigned randomly to receive metoprolol or placebo for 6 months. The primary endpoint was the improvement in cardiac output response to stress, measured by an increase in the left ventricle stroke volume more than 30%. RESULTS Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P=0.057). Diastolic dysfunction was found in two (4.8%) patients before and in five (15.6%) patients after therapy in the metoprolol group, and in 10 (27%) patients before and nine (31%) patients after therapy in the placebo group (P=0.67). After treatment, no echocardiography parameter of morphology was significantly different between metoprolol or placebo groups. No significant differences were observed in noradrenaline, plasma renin activity, and troponin levels between groups. Cirrhosis-related clinical events, including hospitalizations and mortality, were not significantly different between the two groups. Six months of therapy with β-blocker did not ameliorate heart function and morphology in patients with cirrhotic cardiomyopathy.
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115
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Sharma S, Karamchandani K, Wilson R, Baskin S, Bezinover D. Acute heart failure after Orthotopic liver transplantation: a case series from one center. BMC Anesthesiol 2018; 18:102. [PMID: 30064379 PMCID: PMC6069825 DOI: 10.1186/s12871-018-0560-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/17/2018] [Indexed: 01/09/2023] Open
Abstract
Background Patients undergoing liver transplantation (LT) can develop acute heart failure (HF) in the postoperative period despite having had a normal cardiac evaluation prior to surgery. End-stage liver disease is often associated with underlying cardiac dysfunction which, while not identified during preoperative testing, manifests itself during or immediately after surgery. Case presentation We describe three cases of non-ischemic acute HF developing shortly after LT in patients who had a normal preoperative cardiac evaluation. The challenges associated with both diagnosis and management of acute HF in the setting of a newly implanted graft will be discussed. Conclusions Diastolic dysfunction, QTc interval prolongation, and an increase in BNP may be predictive of postoperative HF. Current recommendations for preoperative cardiovascular evaluation of transplant candidates does not include studies examining these risk factors and should be revised. Further investigations are necessary to evaluate these findings.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine/ Penn State Health Milton S. Hershey Medical Center, 500 University Drive, H187, P.O. Box 850, Hershey, PA, 17033-0850, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine/ Penn State Health Milton S. Hershey Medical Center, 500 University Drive, H187, P.O. Box 850, Hershey, PA, 17033-0850, USA
| | - Ryan Wilson
- Department of Cardiology, Penn State College of Medicine/ Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Sean Baskin
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine/ Penn State Health Milton S. Hershey Medical Center, 500 University Drive, H187, P.O. Box 850, Hershey, PA, 17033-0850, USA
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine/ Penn State Health Milton S. Hershey Medical Center, 500 University Drive, H187, P.O. Box 850, Hershey, PA, 17033-0850, USA.
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Flaherty D, Kim S, Zerillo J, Park C, Joseph T, Hill B, Lin HM, Li J, Hamsher C, Weiner MM, DeMaria S. Preoperative QTc Interval is Not Associated With Intraoperative Cardiac Events or Mortality in Liver Transplantation Patients. J Cardiothorac Vasc Anesth 2018; 33:961-966. [PMID: 30097315 DOI: 10.1053/j.jvca.2018.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The primary objective of this study was to determine whether liver transplantation recipients with preoperative prolonged corrected (QTc) intervals have a higher incidence of intraoperative cardiac events and/or postoperative mortality compared with their peers with normal QTc intervals. DESIGN This was a retrospective cohort study. SETTING Single academic hospital in New York, NY. PARTICIPANTS Patients undergoing liver transplantation between 2007 and 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data relating to all liver transplantation recipients with preoperative electrocardiograms were queried from an institutional anesthesia data warehouse and electronic medical records. Primary outcomes were a composite outcome of intraoperative cardiac events and postoperative mortality. Patients with a prolonged QTc interval (>450 ms for men, >470 ms for women) did not demonstrate an association with intraoperative cardiac events, 30- or 90-day mortality, in-hospital mortality, or overall mortality compared with recipients in the normal QTc interval group. A prolonged QTc was found to be associated with increased anesthesia time, surgical time, length of hospital stay, and incidence of fresh frozen plasma and platelets transfusion. CONCLUSIONS Prolonged QTc interval is not associated with an increased incidence of intraoperative cardiac events or mortality in liver transplantation recipients. The demonstrated correlation among QTc length and Model for End-stage Liver Disease score, blood component requirements, surgical and anesthetic times, and hospital length of stay likely represents the association between QTc length and severity of liver disease.
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Affiliation(s)
- Devon Flaherty
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sang Kim
- Department of Anesthesiology, Critical Care and Pain Medicine, Hospital for Special Surgery, New York, NY.
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chang Park
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas Joseph
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bryan Hill
- Department of Anesthesiology, The Ohio State University, Columbus, OH
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jiawen Li
- Department of Biostatistics and Data Management, Abbott Molecular, Des Plaines, IL
| | - Carlyle Hamsher
- Department of Anesthesia and Perioperative Care, Zuckerberg General Hospital and Trauma Center, San Francisco, CA
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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117
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Scarpati G, De Robertis E, Esposito C, Piazza O. Hepatic encephalopathy and cirrhotic cardiomyopathy in Intensive Care Unit. Minerva Anestesiol 2018; 84:970-979. [DOI: 10.23736/s0375-9393.18.12343-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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118
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Vetrugno L, Barnariol F, Bignami E, Centonze GD, De Flaviis A, Piccioni F, Auci E, Bove T. Transesophageal ultrasonography during orthotopic liver transplantation: Show me more. Echocardiography 2018; 35:1204-1215. [PMID: 29858886 DOI: 10.1111/echo.14037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The first perioperative transesophageal echocardiography (TEE) guidelines published 21 years ago were mainly addressed to cardiac anesthesiologists. TEE has since expanded its role outside this setting and currently represents an invaluable tool to assess chamber sizes, ventricular hypertrophy, and systolic, diastolic, and valvular function in patients undergoing orthotopic liver transplantation (OLT). Right-sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) are the most common intra-operative findings described during OLT. However, left ventricular outflow tract obstruction and left ventricular ballooning syndrome are more difficult to recognize and less frequent. Transesophageal ultrasonography (TEU) during OLT is also underused. Its applications are as follows: (1) assistance in the difficult placement of pulmonary arterial catheters; (2) help with catheterization of great vessels for external veno-venous bypass placement; (3) intra-operative evaluation of surgical liver anastomosis patency, if feasible, through the liver window; and (4) intra-operative investigation of "acute hypoxemia" due to pulmonary and cardiac issues using trans-esophageal lung ultrasound (TELU). The aims of this review are as follows: (1) to summarize the uses of TEE and TEU throughout all phases of OLT, and (2) to describe other new feasible applications.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Barnariol
- Anesthesiology and Intensive Care 1, Department of Anesthesia and Intensive Care Medicine, University-Hospital of Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Grazia D Centonze
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Adelisa De Flaviis
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Piccioni
- Department of Critical Care Medicine and Support Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elisabetta Auci
- Anesthesiology and Intensive Care 2, Department of Anesthesia and Intensive Care Medicine, University-Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
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119
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Vetrugno L, Bignami E, Barbariol F, Langiano N, De Lorenzo F, Matellon C, Menegoz G, Della Rocca G. Cardiac output measurement in liver transplantation patients using pulmonary and transpulmonary thermodilution: a comparative study. J Clin Monit Comput 2018; 33:223-231. [PMID: 29725794 DOI: 10.1007/s10877-018-0149-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/26/2018] [Indexed: 11/24/2022]
Abstract
During liver transplantation surgery, the pulmonary artery catheter-despite its invasiveness-remains the gold standard for measuring cardiac output. However, the new EV1000 transpulmonary thermodilution calibration technique was recently introduced into the market by Edwards LifeSciences. We designed a single-center prospective observational study to determine if these two techniques for measuring cardiac output are interchangeable in this group of patients. Patients were monitored with both pulmonary artery catheter and the EV1000 system. Simultaneous intermittent cardiac output measurements were collected at predefined steps: after induction of anesthesia (T1), during the anhepatic phase (T2), after liver reperfusion (T3), and at the end of the surgery (T4). The 4-quadrant and polar plot techniques were used to assess trending ability between the two methods. We enrolled 49 patients who underwent orthotopic liver transplantation surgery. We analyzed a total of 588 paired measurements. The mean bias between pulmonary artery catheter and the EV1000 system was 0.35 L/min with 95% limits of agreement of - 2.30 to 3.01 L/min, and an overall percentage error of 35%. The concordance rate between the two techniques in 4-quadrant plot analysis was 65% overall. The concordance rate of the polar plot showed an overall value of 83% for all pairs. In the present study, in liver transplantation patients we found that intermittent cardiac output monitoring with EV1000 system showed a percentage error compared with pulmonary artery catheter in the acceptable threshold of 45%. On the others hand, our results showed a questionable trending ability between the two techniques.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, P.le S. Maria della Misericordia n.15, 33100, Udine, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126, Parma, Italy
| | - Federico Barbariol
- Anesthesiology and Intensive Care 1, University-Hospital of Udine, P.le S. Maria della Misericordia n.15, 33100, Udine, Italy
| | - Nicola Langiano
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, P.le S. Maria della Misericordia n.15, 33100, Udine, Italy
| | - Francesco De Lorenzo
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, P.le S. Maria della Misericordia n.15, 33100, Udine, Italy
| | - Carola Matellon
- Anesthesiology and Intensive Care 1, University-Hospital of Udine, P.le S. Maria della Misericordia n.15, 33100, Udine, Italy
| | - Giuseppe Menegoz
- Statistical Physics, SISSA, University of Trieste, via Bonomea 265, 34136, Trieste, Italy
| | - Giorgio Della Rocca
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, P.le S. Maria della Misericordia n.15, 33100, Udine, Italy
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120
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Rimbaş RC, Baldea SM, Guerra RDGA, Visoiu SI, Rimbaş M, Pop CS, Vinereanu D. New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:562-574. [PMID: 29306590 DOI: 10.1016/j.ultrasmedbio.2017.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 06/07/2023]
Abstract
There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child-Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.
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Affiliation(s)
- Roxana Cristina Rimbaş
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Sorina Mihăilă Baldea
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Mihai Rimbaş
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Corina Silvia Pop
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, University and Emergency Hospital, Bucharest, Romania
| | - Dragoş Vinereanu
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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121
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Elnegouly M, Umgelter K, Safi W, Hapfelmeier A, Schmid RM, Umgelter A. Elevated cardiac troponin T in cirrhotic patients with emergency care admissions: Associations with mortality. J Gastroenterol Hepatol 2018; 33:518-523. [PMID: 28730699 DOI: 10.1111/jgh.13902] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/03/2017] [Accepted: 07/13/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Mortality of cirrhotic patients after emergency care admission is high, and prognostic factors can help in prioritizing patients. The aim of our study was to assess the association between levels of cardiac troponin T (cTnT) and 1-year mortality in patients with liver cirrhosis without known cardiac disease, who were admitted to the emergency department (ED). METHODS All patients with cirrhosis presented to the ED from October 2009 until August 2015 who had an initial cTnT value measured with the first lab panel were retrospectively analyzed with a follow-up of 365 days. RESULTS Of a total of 237 cirrhotic ED patients, cTnT measurements were available for 87 (63% men, mean age 58.9 ± 11.0 years, and median Model for End-stage Liver Disease score was 15 [25th-75th percentile: 10-19]). Chronic Liver Failure Consortium acute-on-chronic liver failure (CLIF-C-ACLF) score was 33. Forty-three patients (49%) had cTnT values above the normal range (14 ng/L), of which 19 (22%) had values over 30 ng/L. Two patients were lost to follow-up. In multivariable analysis, both CLIF-C-ACLF (hazard ratio 1.072 per point increase; 95% confidence interval 1.029-1.117; P < 0.001) and cTnT (hazard ratio 1.014 per ng/L increase; 95% confidence interval 1.004-1.024; P = 0.008) emerged as independently associated with mortality. CONCLUSIONS A large proportion of cirrhotic patients in the ED have elevated levels of cTnT even if there is no evidence of cardiac disease. Elevated cTnT is associated with increased mortality during 1 year after correcting for Model for End-stage Liver Disease and CLIF-C-ACLF scores.
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Affiliation(s)
- Mayada Elnegouly
- 2nd Medical Department, Technical University of Munich, Munich, Germany.,Department of Infectious Diseases and Endemic Hepatology and Gastroenterology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Katrin Umgelter
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany
| | - Wajima Safi
- Department of Nephrology and Hypertension, Friedrich-Alexander University, Erlangen-Nuremberg, Germany
| | - Alexander Hapfelmeier
- Institute for Medical Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- 2nd Medical Department, Technical University of Munich, Munich, Germany
| | - Andreas Umgelter
- 2nd Medical Department, Technical University of Munich, Munich, Germany
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122
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Vasavan T, Ferraro E, Ibrahim E, Dixon P, Gorelik J, Williamson C. Heart and bile acids - Clinical consequences of altered bile acid metabolism. Biochim Biophys Acta Mol Basis Dis 2018; 1864:1345-1355. [PMID: 29317337 DOI: 10.1016/j.bbadis.2017.12.039] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/11/2022]
Abstract
Cardiac dysfunction has an increased prevalence in diseases complicated by liver cirrhosis such as primary biliary cholangitis and primary sclerosing cholangitis. This observation has led to research into the association between abnormalities in bile acid metabolism and cardiac pathology. Approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy. Bile acids are directly implicated in this, causing QT interval prolongation, cardiac hypertrophy, cardiomyocyte apoptosis and abnormal haemodynamics of the heart. Elevated maternal serum bile acids in intrahepatic cholestasis of pregnancy, a disorder which causes an impaired feto-maternal bile acid gradient, have been associated with fatal fetal arrhythmias. The hydrophobicity of individual bile acids in the serum bile acid pool is of relevance, with relatively lipophilic bile acids having a more harmful effect on the heart. Ursodeoxycholic acid can reverse or protect against these detrimental cardiac effects of elevated bile acids.
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Affiliation(s)
- Tharni Vasavan
- Department of Women and Children's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL London, United Kingdom
| | - Elisa Ferraro
- National Heart and Lung Institute, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, W12 0NN London, United Kingdom
| | - Effendi Ibrahim
- National Heart and Lung Institute, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, W12 0NN London, United Kingdom; Faculty of Medicine, MARA University of Technology, 40000 Sungai Buloh, Malaysia
| | - Peter Dixon
- Department of Women and Children's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL London, United Kingdom
| | - Julia Gorelik
- National Heart and Lung Institute, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, W12 0NN London, United Kingdom
| | - Catherine Williamson
- Department of Women and Children's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL London, United Kingdom.
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123
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Mocarzel LOC, Rossi MM, Miliosse BDM, Lanzieri PG, Gismondi RA. Cirrhotic Cardiomyopathy: A New Clinical Phenotype. Arq Bras Cardiol 2017; 108:564-568. [PMID: 28699978 PMCID: PMC5489327 DOI: 10.5935/abc.20170066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/01/2016] [Indexed: 12/28/2022] Open
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124
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Farouk H, Al-Maimoony T, Nasr A, El-Serafy M, Ghany MA. Echocardiographic assessment of the left ventricular diastolic function in patients with non-alcoholic liver cirrhosis. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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125
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Shah M, Patnaik S, Maludum O, Patil S, De Venecia TA, Figueredo VM. Echocardiographic and Electrocardiographic Predictors of Adverse Outcomes in Spontaneous Bacterial Peritonitis. J Clin Exp Hepatol 2017; 7:321-327. [PMID: 29234197 PMCID: PMC5715479 DOI: 10.1016/j.jceh.2017.05.007] [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] [Received: 12/04/2016] [Accepted: 05/02/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with cirrhosis who develop Spontaneous Bacterial Peritonitis (SBP) suffer from cirrhotic cardiomyopathy which is characterized by impaired contractility in response to stress despite a relatively normal resting cardiac output. We hypothesized that electrocardiographic and echocardiographic information would help prognosticate patients developing SBP in addition to existing scoring systems. METHODS Cirrhotic patients admitted to Einstein Medical Center from 01/01/2005 to 6/30/2012 for SBP, and did not receive a transplant within one year, were included. Patients were classified as QTc low vs. high, and E/E' low vs. high at cut points ≥480 ms for QTc and ≥10 for E/E' ratio. We estimated 1-year survival using Kaplan Meier curves. Regression analysis and Cox proportional hazards model were used for QTc and E/E' ratio, respectively, for assessing 1-year survival. RESULTS Among 112 patients with electrocardiogam, 78 were classified as QTc low. Among 64 patients with echocardiograms, 23 were classified as E/E' low. Higher QTc was associated with increased in-hospital acute kidney injury. QTc and E/E' ratio predicted worse 1-year survival (HR = 2.16, 95% CI 1.29-3.49; HR 2.65, 95% CI 1.31-5.35, respectively) on univariate and multivariate analysis (OR = 1.02, 95% CI 1.01-1.03; HR = 3.26, 95% CI 1.22-9.82 respectively) after adjusting for both Child Pugh stage, MELD score among other risk factors. CONCLUSION In conclusion, cirrhotic patients with SBP who present with a prolonged QTc interval are at a greater risk for acute renal failure during hospitalization. High QTc duration and an E/E' ratio of ≥10 independently predict increased mortality at 1-year follow-up.
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Affiliation(s)
- Mahek Shah
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
- Address for correspondence. Mahek Shah, Lehigh Valley Healthcare Network, Department of Cardiology, Suite 300, Allentown, PA, USA. Tel.: +1 267 648 7561.Lehigh Valley Healthcare Network, Department of CardiologySuite 300AllentownPAUSA
| | - Soumya Patnaik
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Obiora Maludum
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Shantanu Patil
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | | | - Vincent M. Figueredo
- Department of Cardiology, Einstein Medical Center, Philadelphia, PA, USA
- Sydney Kimmel Medical College, Philadelphia, PA, USA
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126
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The Outcome of Thoracentesis versus Chest Tube Placement for Hepatic Hydrothorax in Patients with Cirrhosis: A Nationwide Analysis of the National Inpatient Sample. Gastroenterol Res Pract 2017; 2017:5872068. [PMID: 29317865 PMCID: PMC5727694 DOI: 10.1155/2017/5872068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/24/2017] [Accepted: 10/10/2017] [Indexed: 02/07/2023] Open
Abstract
There are only a few studies with a small sample size of patients that have compared the risks of using chest tubes versus thoracentesis in hepatic hydrothorax. It has been shown that many complications may arise secondary to chest tube placement and is associated with increased morbidity and mortality. In this retrospective study, patients with cirrhosis were identified from the 2009 National Inpatient Sample by using ICD-9 codes; we evaluated the risk of chest tube versus thoracentesis in a largest population with hepatic hydrothorax to date to measure the mortality and the length of stay. A total of 140,573 patients with liver cirrhosis were identified. Of this, 1981 patients had a hepatic hydrothorax and ended up with either thoracentesis (1776) or chest tube (205). The mortality in those who received a chest tube was two times higher than that in thoracentesis group with a P value of ≤0.001 (CI 1.43–312). In addition, the length of hospital stay of the chest tube group was longer than that of the thoracentesis subset (7.2 days versus 3.8 days, resp.). We concluded that chest tube placement has two times higher mortality rate and longer hospital length of stay when compared to patients who underwent thoracentesis.
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127
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A Case of Refractory Pulmonary Coccidioidomycosis Successfully Treated with Posaconazole Therapy. ACTA ACUST UNITED AC 2017. [PMID: 29938709 DOI: 10.14260/jemds/2017/1130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Coccidioidomycosis is an endemic fungal infection caused by the inhalation of the spores of Coccidioides species. Patients with underlying immunosuppressive illness can contract chronic or disseminated disease which requires prolonged systemic therapy. Pulmonary coccidioidomycosis remains as an illusory and abstruse disease, with increased prevalence that poses as a challenge for clinicians in developing an effective strategy for treatment. Here, we report successful treatment of a refractory case of chronic relapsing pulmonary coccidioidomycosis in a 50-year old woman with a thin-walled cavitary lung lesion who was ultimately treated with posaconazole.
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128
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Kennedy ND, Winter DC. Impact of alcohol & smoking on the surgical management of gastrointestinal patients. Best Pract Res Clin Gastroenterol 2017; 31:589-595. [PMID: 29195679 DOI: 10.1016/j.bpg.2017.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/24/2017] [Accepted: 10/20/2017] [Indexed: 01/31/2023]
Abstract
Alcohol and smoking are repeatedly described as modifiable risk factors in clinical studies across all surgical specialities. These lifestyle choices impart a sub-optimal physiology via multiple processes and play an important role in the surgical management of the gastrointestinal patient. Cessation is imperative to optimise the patient's fitness for surgery with surgery itself being a prime opportunity for sustained cessation. A consistent, planned and integrated management involving surgical, anaesthetic, medical, and primary care facets will aid in successful cessation and perioperative care. This review highlights the pathological processes which contribute to perioperative complications and details the current practices to detect, predict and appropriately manage the perioperative gastrointestinal patient who smokes and consumes alcohol.
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Affiliation(s)
- Niall D Kennedy
- St Vincents University Hospital, Elm Park, Dublin 4, Ireland.
| | - Des C Winter
- St Vincents University Hospital, Elm Park, Dublin 4, Ireland
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129
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Voiosu A, Wiese S, Voiosu T, Bendtsen F, Møller S. Bile acids and cardiovascular function in cirrhosis. Liver Int 2017; 37:1420-1430. [PMID: 28222247 DOI: 10.1111/liv.13394] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/12/2017] [Indexed: 02/13/2023]
Abstract
Cirrhotic cardiomyopathy and the hyperdynamic syndrome are clinically important complications of cirrhosis, but their exact pathogenesis is still partly unknown. Experimental models have proven the cardiotoxic effects of bile acids and recent studies of their varied receptor-mediated functions offer new insight into their involvement in cardiovascular dysfunction in cirrhosis. Bile acid receptors such as farnesoid X-activated receptor and TGR5 are currently under investigation as potential therapeutic targets in a variety of pathological conditions. These receptors have also recently been identified in cardiomyocytes, vascular endothelial cells and smooth muscle cells where they seem to play an important role in cellular metabolism. Chronic cholestasis leading to abnormal levels of circulating bile acids alters the normal signalling pathways and contributes to the development of profound cardiovascular disturbances. This review summarizes the evidence regarding the role of bile acids and their receptors in the generation of cardiovascular dysfunction in cirrhosis.
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Affiliation(s)
- Andrei Voiosu
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.,Gastroenterology and Hepatology Department, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Signe Wiese
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Theodor Voiosu
- Gastroenterology and Hepatology Department, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Flemming Bendtsen
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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130
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Abstract
The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, and the impact of ischemia-reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.
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Affiliation(s)
- Dieter Adelmann
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, Box O648, 4th Floor MUE, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Kate Kronish
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, Box O648, 4th Floor MUE, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Michael A Ramsay
- Department of Anesthesiology, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
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131
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Chan KC, Yeh JR, Sun WZ. The role of autonomic dysfunction in predicting 1-year mortality after liver transplantation. Liver Int 2017; 37:1239-1248. [PMID: 28107591 DOI: 10.1111/liv.13364] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/08/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Model for end-stage liver disease (MELD) score has been extensively used to prioritize patients for liver transplantation and determine their prognosis, but with limited predictive value. Autonomic dysfunction may correlate with increased mortality after liver transplant. In this study, two autonomic biomarkers, complexity and deceleration capacity, were added to the predicting model for 1-year mortality after liver transplantation. METHODS In all, 30 patients with end-stage liver diseases awaiting liver transplantation were included. Complexity and deceleration capacity were calculated by multi-scale entropy and phase-rectified signal averaging, respectively. Different combinations of autonomic factors and MELD score were used to predict mortality rate of liver transplant after 1-year follow-up. Receiver-operating characteristics curve analysis was performed to determine clinical predictability. Area under the receiver-operating characteristics curve represents the overall accuracy. RESULTS The 1-year mortality rate was 16.7% (5/30). The overall accuracy of MELD score used for predicting mortality after liver transplantation was 0.752. By adding complexity and deceleration capacity into the predicting model, the accuracy increased to 0.912. Notably, the accuracy of the prediction using complexity and deceleration capacity alone was 0.912. CONCLUSION Complexity and deceleration capacity, which represent different dynamical properties of a human autonomic system, are critical factors for predicting mortality rate of liver transplantation. We recommend that these pre-operative autonomic factors may be helpful as critical adjuncts to predicting model of mortality rate in prioritizing organ allocation.
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Affiliation(s)
- Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Rong Yeh
- Research Center for Adaptive Data Analysis and Center for Dynamical Biomarkers and Translational Medicine, National Central University, Taoyuan, Taiwan
| | - Wei-Zen Sun
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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132
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Zhao J, Li S, Ren L, Guo X, Qi X. Pro-Brain Natriuretic Peptide and Troponin T-Hypersensitivity Levels Correlate With the Severity of Liver Dysfunction in Liver Cirrhosis. Am J Med Sci 2017; 354:131-139. [PMID: 28864370 DOI: 10.1016/j.amjms.2017.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/20/2017] [Accepted: 04/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Increased pro-brain natriuretic peptide (pro-BNP) or troponin T-hypersensitivity (TnT-HSST) levels are common in liver cirrhosis. We conducted a retrospective observational study aimed to evaluate the correlation of pro-BNP and TnT-HSST levels with the clinical characteristics, laboratory data and in-hospital outcomes of patients with liver cirrhosis. MATERIALS AND METHODS We selected cirrhotic patients admitted to our hospital between January 2011 and June 2014. All eligible patients had pro-BNP or TnT-HSST data, or both. The pro-BNP and TnT-HSST data were further divided according to the presence of cardiac diseases. RESULTS The prevalence of pro-BNP level >900pg/mL was 41.72% (63 of 151 patients). The prevalence of TnT-HSST level >0.05ng/mL was 11.22% (45 of 401 patients). In the overall analysis, pro-BNP level significantly correlated with red blood cell (RBC), platelet, ascites, blood urea nitrogen (BUN), creatinine (Cr), Child-Pugh score, model for end-stage liver disease (MELD) score and in-hospital death; TnT-HSST level significantly correlated with white blood cell, ascites, albumin (ALB), BUN, Cr, Child-Pugh score, MELD score and in-hospital death. In patients with cardiac diseases, pro-BNP level significantly correlated with RBC, ascites, BUN, Cr, Child-Pugh score and MELD score; TnT-HSST level significantly correlated with sex, ascites, white blood cell, ALB, BUN, Cr, Child-Pugh score, MELD score and in-hospital death. In patients without cardiac diseases, pro-BNP level significantly correlated with ascites, RBC, platelet, BUN, Cr, MELD score and in-hospital death; TnT-HSST level significantly correlated with age, ascites, RBC, ALB, BUN, Cr, Child-Pugh score, MELD score and in-hospital death. CONCLUSIONS Pro-BNP and TnT-HSST levels significantly correlated with the severity of liver dysfunction and in-hospital mortality in cirrhosis.
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Affiliation(s)
- Jiancheng Zhao
- Department of Gastroenterology (JZ, LR, XG, XQ), General Hospital of Shenyang Military Area, Shenyang, China; Department of Rehabilitation (JZ), Jia He Hospital of the Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Sai Li
- Department of Cardiology (SL), No. 4 People's Hospital of Shenyang City, Shenyang, China
| | - Linan Ren
- Department of Rehabilitation (JZ), Jia He Hospital of the Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xiaozhong Guo
- Department of Rehabilitation (JZ), Jia He Hospital of the Liaoning University of Traditional Chinese Medicine, Shenyang, China.
| | - Xingshun Qi
- Department of Rehabilitation (JZ), Jia He Hospital of the Liaoning University of Traditional Chinese Medicine, Shenyang, China.
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Fas Receptor Activation by Endogenous Opioids Is A New Mechanism for Cardiomyopathy in Cirrhotic Rats. J Clin Exp Hepatol 2017; 7:107-114. [PMID: 28663674 PMCID: PMC5478937 DOI: 10.1016/j.jceh.2016.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/12/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cirrhosis, a common consequence of chronic liver inflammation is associated with various cardiovascular dysfunctions which are called cirrhotic cardiomyopathy (CC). Among the various possible causes of CC, apoptosis is considered to have a pivotal role. OBJECTIVES To explore the contribution of endogenous opioids in the apoptosis process in a rat model of CC. MATERIAL AND METHODS Four genes were selected to cover both intrinsic and extrinsic pathways of apoptosis. Cardiac samples from 4 groups of rats were evaluated. Two groups were cirrhotic through bile duct ligation (BDL) receiving either naltrexone (BDL-naltrexone) or saline (BDL-saline), two others were normal rats as sham groups receiving either naltrexone (sham-naltrexone) or saline (sham-saline). Expression level of BCL2, Caspase3, Fas and FasL was explored in all groups using reverse transcriptase real-time PCR. RESULTS BDL-saline group showed significant over-expression of BCL2, caspase3 and Fas. BCL2 expression was 1.44 (P < 0.001) and caspasse3 was 1.35 (P < 0.001) times higher than sham-saline group, Fas was also overexpressed 1.3 (P < 0.001) times higher than BDL-naltrexone group and 1.91 (P < 0.001) compared to sham-naltrexone group. Caspase3 expression was 1.35 (P < 0.001) folds higher than sham-naltrexone group. The expression pattern of FasL revealed no statistically significant change among study groups. CONCLUSION Fas molecule enrollment during CC is a novel finding. Fas molecule is activated during cirrhosis through elevated levels of endogenous opioids. This pathway is one of the leading causes of CC. Our findings also demonstrated the protective role of naltrexone as opioids antagonist on cardiomyocytes in a rat model of CC.
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Sang BH, Kim JW, Yoo JI, Bang YS, Choi YS, Moon YJ, Hwang GS, Lim YS. Pretransplant diastolic wall strain assessed by transthoracic echocardiography and its implication on posttransplant survival rate in liver transplantation. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.2.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Bo-Hyun Sang
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Jung-Won Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Jee-In Yoo
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Yun-Sic Bang
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Young Soon Choi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Su Lim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon, Korea
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Taura P, Martinez-Palli G, Blasi A, Rivas E, Beltran J, Balust J. Intraoperative Management of High-Risk Liver Transplant Recipients: Concerns and Challenges. Transplant Proc 2017; 48:2491-2494. [PMID: 27742332 DOI: 10.1016/j.transproceed.2016.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Liver transplantation (LT) offers patients with liver disease a real chance for long-term survival. In the past decade, successful survival after LT along with the Model for End-Stage Liver Disease-based allocation policy have increased willingness to accept patients with a higher risk profile and marginal organs and to prioritize the sickest patients on the waiting list. Therefore, the anesthesiologist now deals with very challenging patients. In the present review, we aimed to highlight key aspects of intraoperative LT management in high-risk patients and to place these aspects in the perspective of their impact on perioperative outcomes. Conservative standardized perioperative strategies mandate a switch toward accurate and tailored perioperative anesthetic care to maintain the steady improvement in recipient survival rates after LT. In our opinion, continuous assessment of fluid status and cardiac performance, strategies promoting graft decongestion, rational hemostatic management, and the identification of LT recipients with potential risk of vascular complications should constitute the cornerstone of intraoperative management.
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Affiliation(s)
- P Taura
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
| | - G Martinez-Palli
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - A Blasi
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - E Rivas
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - J Beltran
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - J Balust
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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136
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Baibhav B, Mahabir CA, Xie F, Shostrom VK, McCashland TM, Porter TR. Predictive Value of Dobutamine Stress Perfusion Echocardiography in Contemporary End-Stage Liver Disease. J Am Heart Assoc 2017; 6:JAHA.116.005102. [PMID: 28219921 PMCID: PMC5523784 DOI: 10.1161/jaha.116.005102] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The assessment of cardiac risk in contemporary liver transplantation (LT) has required more sensitive testing for the detection of occult coronary artery disease as well as microvascular and functional cardiac abnormalities. Because dobutamine stress perfusion echocardiography provides an assessment of both regional systolic and diastolic function as well as microvascular perfusion (MVP), we sought to examine its incremental value in this setting. METHODS AND RESULTS We evaluated the predictive value of dobutamine stress perfusion echocardiography in 296 adult patients with end-stage liver disease and preserved systolic function who underwent LT between 2008 and 2014. The primary outcome was cardiovascular death, nonfatal myocardial infarction, and/or sustained ventricular arrhythmias following LT. The main causes of liver failure were hepatitis C (25%) and nonalcoholic fatty liver disease (13%). Abnormal MVP during stress was observed in 18 patients (6%), whereas diastolic dysfunction was present in 109 patients (94 grade 1, 15 grade 2). Half of the patients (7 of 14) referred for angiography with abnormal MVP had significant epicardial disease by angiography, and these patients were revascularized prior to LT. Despite these interventions, the primary outcome still occurred in 9 patients (3%). Patients with abnormal MVP during dobutamine stress perfusion echocardiography had a 7-fold higher risk of a cardiovascular event following LT. Cox proportional hazards modeling examining clinical variables, left ventricular ejection fraction, diastolic function, and stress-induced wall motion abnormalities or MVP defects demonstrated that abnormal MVP was the only independent predictor of the primary outcome (P=0.004; hazard ratio 7.7). CONCLUSIONS Stress MVP assessments are highly predictive of cardiovascular outcome in current LT candidates.
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Affiliation(s)
| | | | - Feng Xie
- University of Nebraska Medical Center, Omaha, NE
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137
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Desai M, Mathur B, Eblimit Z, Vasquez H, Taegtmeyer H, Karpen S, Penny DJ, Moore DD, Anakk S. Bile acid excess induces cardiomyopathy and metabolic dysfunctions in the heart. Hepatology 2017; 65:189-201. [PMID: 27774647 PMCID: PMC5299964 DOI: 10.1002/hep.28890] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 09/07/2016] [Accepted: 09/30/2016] [Indexed: 12/31/2022]
Abstract
UNLABELLED Cardiac dysfunction in patients with liver cirrhosis is strongly associated with increased serum bile acid concentrations. Here we show that excess bile acids decrease fatty acid oxidation in cardiomyocytes and can cause heart dysfunction, a cardiac syndrome that we term cholecardia. Farnesoid X receptor; Small Heterodimer Partner double knockout mice, a model for bile acid overload, display cardiac hypertrophy, bradycardia, and exercise intolerance. In addition, double knockout mice exhibit an impaired cardiac response to catecholamine challenge. Consistent with this decreased cardiac function, we show that elevated serum bile acids reduce cardiac fatty acid oxidation both in vivo and ex vivo. We find that increased bile acid levels suppress expression of proliferator-activated receptor-γ coactivator 1α, a key regulator of fatty acid metabolism, and that proliferator-activated receptor-γ coactivator 1α overexpression in cardiac cells was able to rescue the bile acid-mediated reduction in fatty acid oxidation genes. Importantly, intestinal bile acid sequestration with cholestyramine was sufficient to reverse the observed heart dysfunction in the double knockout mice. CONCLUSIONS Decreased proliferator-activated receptor-γ coactivator 1α expression contributes to the metabolic dysfunction in cholecardia so that reducing serum bile acid concentrations may be beneficial against the metabolic and pathological changes in the heart. (Hepatology 2017;65:189-201).
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Affiliation(s)
- Moreshwar Desai
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | - Bhoomika Mathur
- Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Zeena Eblimit
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | - Hernan Vasquez
- Dept. of Cardiology University of Texas Health Sciences Center, Houston, TX
| | | | - Saul Karpen
- Pediatric Gastroenterology, Emory School of Medicine, Atlanta, GA
| | - Daniel J. Penny
- Department of Pediatric Cardiology, Baylor College of Medicine, Houston, TX
| | - David D. Moore
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX
| | - Sayeepriyadarshini Anakk
- Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign, Urbana, IL
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138
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Chou AH, Chen TH, Chen CY, Chen SW, Lee CW, Liao CH, Wang SY. Long-Term Outcome of Cardiac Surgery in 1,040 Liver Cirrhosis Patient ― Nationwide Population-Based Cohort Study ―. Circ J 2017; 81:476-484. [DOI: 10.1253/circj.cj-16-0849] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
- Department of Medicine, Chang Gung University
- Transgenic and Molecular Immunogenetics Laboratory, Chang Gung Memorial Hospital
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch and Linkou Medical Center
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
- Graduate Institute of Clinical Medical Sciences College of Medicine, Chang Gung University
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Chao-Wei Lee
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Chien-Hung Liao
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Shang-Yu Wang
- Graduate Institute of Clinical Medical Sciences College of Medicine, Chang Gung University
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
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139
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Electrocardiographic and echocardiographic changes in patients undergoing liver transplant stratified by outcomes. Int J Cardiol 2016; 223:699-700. [PMID: 27568992 DOI: 10.1016/j.ijcard.2016.08.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 08/03/2016] [Indexed: 11/21/2022]
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140
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Neviere R, Trinh-Duc P, Hulo S, Edme JL, Dehon A, Boleslawski E, Dharancy S, Lebuffe G. Predictive value of exhaled nitric oxide and aerobic capacity for sepsis complications after liver transplantation. Transpl Int 2016; 29:1307-1316. [PMID: 27649520 DOI: 10.1111/tri.12861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/27/2016] [Accepted: 09/12/2016] [Indexed: 12/17/2022]
Abstract
Our objective was to investigate the predictive value of fractional nitric oxide (NO) concentration in exhaled breath (FeNO) and aerobic capacity (peak VO2 ) for postoperative sepsis in liver transplantation candidates. Patients were identified and charts of all consecutive patients were prospectively reviewed. Bacterial sepsis represented the commonest postoperative complications (30%), which was attributed to peritonitis, pneumonia, and catheter-related infections. Preoperative FeNO and peak VO2 values were lower in patients with postoperative sepsis. Patients with sepsis required higher needs for mechanical ventilation and ICU length of stay. Inverse correlation was found between logarithmically FeNO-transformed data and systolic pulmonary artery pressure (r = -0.348; P = 0.018). Multivariate analyses using bootstrap sampling method indicated that odds of sepsis were associated with lower values of peak exercise VO2 [OR = 0.790 (0.592; 0.925)] and reduced log(FeNo) [OR = 0.027 (0.001; 0.451)], but not with higher MELD scores [OR = 1.141 (0.970; 1.486)]. By evaluating the cutoff for the ROC curves in each bootstrap resampling, median and 95% confidence interval were calculated for peak VO2 : 17 [16.2; 22] ml/kg/min and FeNO: 17.2 [13.0; 33.9] ppb. We conclude that low peak exercise VO2 and reduced FeNO may help identify patients who are at risk to develop perioperative sepsis.
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Affiliation(s)
- Remi Neviere
- Service d'Explorations Fonctionnelles Respiratoires, Hôpital Calmette, CHU Lille, Lille, France.,Département de Physiologie, Faculté of Médicine - INSERM U995, Université Lille, Lille, France
| | | | - Sébastien Hulo
- Service d'Explorations Fonctionnelles Respiratoires, Hôpital Calmette, CHU Lille, Lille, France.,Département de Médecine du Travail, EA4483 Faculté of Médicine, Université Lille, Lille, France
| | - Jean Louis Edme
- Service d'Explorations Fonctionnelles Respiratoires, Hôpital Calmette, CHU Lille, Lille, France.,Département de Médecine du Travail, EA4483 Faculté of Médicine, Université Lille, Lille, France
| | - Aurélie Dehon
- Pôle d'Anesthésie Réanimation ADRU, CHU Nîmes, Lille, France
| | - Emmanuel Boleslawski
- Service de Chirurgie Digestive et de Transplantation, Hôpital Huriez, CHU Lille, Lille, France
| | - Sébastien Dharancy
- Service des Maladies de l'Appareil Digestif et de la Nutrition, Hôpital Huriez, CHU Lille, Lille, France
| | - Gilles Lebuffe
- Pôle d'Anesthésie Réanimation, Université de Lille, CHU Lille, EA7365 - GRITA - Groupe de Recherche sur les Formes Injectables et technologies Associées, Lille, France
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141
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Licata A, Novo G, Colomba D, Tuttolomondo A, Galia M, Camma' C. Cardiac involvement in patients with cirrhosis: a focus on clinical features and diagnosis. J Cardiovasc Med (Hagerstown) 2016; 17:26-36. [PMID: 26065511 DOI: 10.2459/jcm.0000000000000288] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cirrhotic heart has been traditionally considered protected from cardiovascular disease, even if a large amount of literature has recently shown that patients affected by chronic liver disease are exposed to cardiovascular events, as well. Since the first recognition of cardiac involvement in cirrhosis, all published studies explain that decompensated cirrhotic patients suffer from haemodynamic changes, currently known as hyperdynamic syndrome, which finally lead to cirrhotic cardiomyopathy. This is defined by the presence of a subclinical systolic dysfunction unmasked under stress conditions, impaired diastolic function and electrophysiological abnormalities, in the absence of any known cardiac disease. In this review, we will discuss the clinical and diagnostic features of this condition, the prevalence of associated comorbidities, echocardiographic, electrocardiographic and cardiac magnetic resonance hallmarks and the possible diagnostic role of serum biomarkers.
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Affiliation(s)
- Anna Licata
- aSezione di Gastroenterologia ed Epatologia bSezione di Medicina Clinico-Sperimentale, Dipartimento di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Italy cDivisione di Cardiologia dSezione di Radiologia, Dipartimento di Biopatologia e Biotecnologie Mediche, DiBiMEF, Università di Palermo, Palermo, Italy
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Zhao J, Qi X, Hou F, Ning Z, Zhang X, Deng H, Peng Y, Li J, Wang X, Li H, Guo X. Prevalence, Risk Factors and In-hospital Outcomes of QTc Interval Prolongation in Liver Cirrhosis. Am J Med Sci 2016; 352:285-95. [PMID: 27650234 DOI: 10.1016/j.amjms.2016.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 06/05/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND QTc interval prolongation is an electrocardiographic abnormality in liver cirrhosis. The objective of this study was to evaluate the prevalence, risk factors and in-hospital outcomes of QTc interval prolongation in Chinese patients with liver cirrhosis. METHODS This was a retrospective analysis of a total of 1,268 patients with liver cirrhosis who were consecutively admitted to our hospital between January 2011 and June 2014. QTc interval data were collected from the medical records. QTc interval prolongation was defined as QTc interval > 440 milliseconds. RESULTS The prevalence of QTc interval prolongation was 38.2% (485 of 1268). In the entire cohort, the risk factors for QTc interval prolongation included an older age, a higher proportion of alcohol abuse and ascites, higher bilirubin, blood urea nitrogen, creatinine, prothrombin time, international normalized ratio, Child-Pugh score and model for end-stage liver diseases score, and lower red blood cell (RBC), hemoglobin (Hb), albumin (ALB), alanine aminotransferase and calcium. The in-hospital mortality was not significantly different between patients with and without QTc interval prolongation (2.1% versus 1.3%, P = 0.276). In the subgroup analyses of patients with hepatitis B virus or alcohol alone-related liver cirrhosis, the risk factors included higher bilirubin, creatinine, prothrombin time, international normalized ratio, Child-Pugh score and model for end-stage liver diseases score, and lower RBC, Hb and ALB. In the subgroups analyses of patients with acute upper gastrointestinal bleeding or ascites, the risk factors included lower RBC, Hb and ALB. CONCLUSIONS QTc interval prolongation was frequent in liver cirrhosis. Although QTc interval prolongation was positively associated with alcohol-related liver cirrhosis and more severe liver dysfunction, it did not significantly influence the in-hospital mortality.
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Affiliation(s)
- Jiancheng Zhao
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China.
| | - Feifei Hou
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China
| | - Zheng Ning
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Dalian Medical University, Dalian, Liaoning, China
| | - Xintong Zhang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Han Deng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Dalian Medical University, Dalian, Liaoning, China
| | - Ying Peng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Dalian Medical University, Dalian, Liaoning, China
| | - Jing Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Dalian Medical University, Dalian, Liaoning, China
| | - Xiaoxi Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China; Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning, China.
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Gerardin J, Rodriguez F, Saraf A, Book WM. Heart transplantation in adults for Fontan failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Shih PY, Lin WY, Hung MH, Cheng YJ, Chan KC. Evaluation of cardiac output by bioreactance technique in patients undergoing liver transplantation. ACTA ACUST UNITED AC 2016; 54:57-61. [PMID: 27461188 DOI: 10.1016/j.aat.2016.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/07/2016] [Accepted: 06/13/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study compared the cardiac output (CO) obtained from PiCCO with that obtained from the noninvasive NICOM method. METHODS Twenty-one cirrhotic patients receiving liver transplantation were enrolled. During the operation, their CO was measured by the PiCCO system via the thermodilution method as the standard and by the NICOM method. Two parameters including cardiac index (CI) and stroke volume index (SVI) were collected simultaneously at three phases during the surgery including the dissection phase (T1), the anhepatic phase (T2), and the reperfusion phase (T3). Correlation, Bland and Altman methods, and linear mixed model were used to evaluate the monitoring ability of both systems. RESULTS Poor correlation was noted between the data measured by NICOM and PiCCO; the correlation coefficients for CI and SVI measured between the two systems were 0.32 and 0.39, respectively. Bland and Altman analysis showed the percentage error of CI as 63.7%, and that of SVI as 66.6% for NICOM compared to PiCCO. Using the linear mixed model, the CI and SVI measured using NICOM were significantly higher than those using PiCCO (estimated regression coefficient 0.92 and 10.77, both p < 0.001). Mixed model analysis showed no differences between the trends of CI and SVI measured by the two methods. CONCLUSIONS NICOM provided a comparable CI and SVI trend when compared to the gold standard PiCCO, but it raises concerns as an effective CO monitor because of its tendency to overestimate CI and SVI especially during the state of high cardiac output.
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Affiliation(s)
- Po-Yuan Shih
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Ying Lin
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Hui Hung
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
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145
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Parker MW, Aurigemma GP. Cardiac Structure and Function in Hyperaldosteronism. Circ Cardiovasc Imaging 2016; 9:CIRCIMAGING.116.005064. [DOI: 10.1161/circimaging.116.005064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Matthew W. Parker
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, University of Massachusetts Memorial Healthcare, Worcester
| | - Gerard P. Aurigemma
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, University of Massachusetts Memorial Healthcare, Worcester
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146
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Carl DE, Ghosh SS, Gehr TWB, Abbate A, Toldo S, Sanyal AJ. A model of acute kidney injury in mice with cirrhosis and infection. Liver Int 2016; 36:865-73. [PMID: 26583566 DOI: 10.1111/liv.13023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/17/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infectious acute kidney injury (AKI) is a life threatening complication of cirrhosis with limited therapeutic options. The aim of this study was to develop a model of infectious AKI in cirrhotic mice. METHODS Cirrhosis was established by intragastric administration of carbon tetrachloride (CCl4 ). Systemic haemodynamics was assessed invasively while cardiac function was assessed by echocardiography. AKI was induced using varying doses of lipopolysaccharide (LPS) titrated to produce 50% lethality. Renal function was assessed from serum creatinine and urine output (UOP). Renal injury was evaluated by urinalysis (proteinuria and casts) and renal histology. These mice were compared to: (i) normal mice, (ii) normal mice + LPS, and (iii) mice treated with CCl4 alone. RESULTS Cirrhosis with increased cardiac output, decreased systemic vascular resistance, activation of renin-angiotensin-aldosterone axis developed after 12 weeks of CCl4 administration. LPS injection produced a dose-dependent increase in mortality (33% at 2 mg/kg vs. 80% at 6 mg/kg) without urine (casts or proteinuria) or histological evidence of tubular injury. 2 mg/kg LPS injection produced a rise in creatinine (0.79 ± 0.27 mg/dl in CCl4 +LPS compared to 0.45 ± 0.14 in CCl4 alone, P < 0.05) and a decrease in UOP (0.86 ± 0.4 ml/16 h in CCl4 + LPS compared to 1.70 ± 0.7 ml/16 h in CCl4 mice, P < 0.05). UOP remained low in mice that died while it recovered over 48-72 h in those that recovered. Control mice treated with 2 mg/kg LPS did not experience AKI. CONCLUSIONS Cirrhotic CCl4 treated mice develop functional AKI and mimic most of the features of infectious AKI following LPS injection.
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Affiliation(s)
- Daniel E Carl
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Siddhartha S Ghosh
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Todd W B Gehr
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Stefano Toldo
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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147
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Krowka MJ. Cardiopulmonary examination. Clin Liver Dis (Hoboken) 2016; 7:116-118. [PMID: 31041044 PMCID: PMC6490271 DOI: 10.1002/cld.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/25/2016] [Indexed: 02/04/2023] Open
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148
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Saeedi Saravi SS, Ghazi-Khansari M, Ejtemaei Mehr S, Nobakht M, Mousavi SE, Dehpour AR. Contribution of mammalian target of rapamycin in the pathophysiology of cirrhotic cardiomyopathy. World J Gastroenterol 2016; 22:4685-94. [PMID: 27217700 PMCID: PMC4870075 DOI: 10.3748/wjg.v22.i19.4685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 02/27/2016] [Accepted: 03/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the role of mammalian target of rapamycin (mTOR) in the pathogenesis of cirrhotic cardiomyopathy and the potential of rapamycin to improve this pathologic condition.
METHODS: Male albino Wistar rats weighing 100-120 g were treated with tetrachloride carbon (CCl4) for 8 wk to induce cirrhosis. Subsequently, animals were administered rapamycin (2 mg/kg per day). The QTc intervals were calculated in a 5-min electrocardiogram. Then, the left ventricular papillary muscles were isolated to examine inotropic responsiveness to β-adrenergic stimulation using a standard organ bath equipped by Powerlab system. Phosphorylated-mTOR localization in left ventricles was immunohistochemically assessed, and ventricular tumor necrosis factor (TNF)-α was measured. Western blot was used to measure levels of ventricular phosphorylated-mTOR protein.
RESULTS: Cirrhosis was confirmed by hematoxylin and eosin staining of liver tissues, visual observation of lethargy, weight loss, jaundice, brown urine, ascites, liver stiffness, and a significant increase of spleen weight (P < 0.001). A significant prolongation in QTc intervals occurred in cirrhotic rats exposed to CCl4 (P < 0.001), while this prolongation was decreased with rapamycin treatment (P < 0.01). CCl4-induced cirrhosis caused a significant decrease of contractile responsiveness to isoproterenol stimulation and a significant increase in cardiac TNF-α. These findings were correlated with data from western blot and immunohistochemical studies on phosphorylated-mTOR expression in left ventricles. Phosphorylated-mTOR was significantly enhanced in cirrhotic rats, especially in the endothelium, compared to controls. Rapamycin treatment significantly increased contractile force and myocardial localization of phosphorylated-mTOR and decreased cardiac TNF-α concentration compared to cirrhotic rats with no treatment.
CONCLUSION: In this study, we demonstrated a potential role for cardiac mTOR in the pathophysiology of cirrhotic cardiomyopathy. Rapamycin normalized the inotropic effect and altered phosphorylated-mTOR expression and myocardial localization in cirrhotic rats.
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Affiliation(s)
- Seyed Soheil Saeedi Saravi
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Mahmoud Ghazi-Khansari
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Shahram Ejtemaei Mehr
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Maliheh Nobakht
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Seyyedeh Elaheh Mousavi
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Ahmad Reza Dehpour
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
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Abstract
Heart failure affects ≈23 million people worldwide and continues to have a high mortality despite advancements in modern pharmacotherapy and device therapy. HF is a complex clinical syndrome that can result in the impairment of endocrine, hematologic, musculoskeletal, renal, respiratory, peripheral vascular, hepatic, and gastrointestinal systems. Although gastrointestinal involvement and hepatic involvement are common in HF and are associated with increased morbidity and mortality, their bidirectional association with HF progression remains poorly fathomed. The current understanding of multiple mechanisms, including proinflammatory cytokine milieu, hormonal imbalance, and anabolic/catabolic imbalance, has been used to explain the relationship between the gut and HF and has been the basis for many novel therapeutic strategies. However, the failure of these novel therapies such as anti–tumor necrosis factor-α has resulted in further complexity. In this review, we describe the involvement of the gastrointestinal and liver systems within the HF syndrome, their pathophysiological mechanisms, and their clinical consequences.
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Affiliation(s)
- Varun Sundaram
- From Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (V.S.); and Division of Cardiovascular Medicine, University of Utah Health Science Center, Salt Lake City (J.C.F.)
| | - James C. Fang
- From Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (V.S.); and Division of Cardiovascular Medicine, University of Utah Health Science Center, Salt Lake City (J.C.F.)
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150
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Lopez-Delgado JC, Ballus J, Esteve F, Betancur-Zambrano NL, Corral-Velez V, Mañez R, Betbese AJ, Roncal JA, Javierre C. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol 2016; 22:2657-2667. [PMID: 26973406 PMCID: PMC4777990 DOI: 10.3748/wjg.v22.i9.2657] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.
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