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Triposkiadis F, Starling RC, Boudoulas H, Giamouzis G, Butler J. The cardiorenal syndrome in heart failure: cardiac? renal? syndrome? Heart Fail Rev 2013; 17:355-66. [PMID: 22086438 DOI: 10.1007/s10741-011-9291-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There has been increasing interest on the so-called cardiorenal syndrome (CRS), defined as a complex pathophysiological disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other. In this review, we contend that there is lack of evidence warranting the adoption of a specific clinical construct such as the CRS within the heart failure (HF) syndrome by demonstrating that: (a) the approaches and tools regarding the definition of kidney involvement in HF are suboptimal; (b) development of renal failure in HF is often confounded by age, hypertension, and diabetes; (c) worsening of renal function (WRF) in HF may be largely independent of alterations in cardiac function; (d) the bidirectional association between HF and renal failure is not unique and represents one of the several such associations encountered in HF; and (e) inflammation is a common denominator for HF and associated noncardiac morbidities. Based on these arguments, we believe that dissecting one of the multiple bidirectional associations in HF and constructing the so-called cardiorenal syndrome is not justified pathophysiologically. Fully understanding of all morbid associations and not only the cardiorenal is of great significance for the clinician who is caring for the patient with HF.
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202
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Ali A, Bhardwaj HL, Heuman DM, Jovin IS. Coronary events in patients undergoing orthotopic liver transplantation: perioperative evaluation and management. Clin Transplant 2013; 27:E207-15. [DOI: 10.1111/ctr.12113] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/12/2022]
Affiliation(s)
| | - Hem L. Bhardwaj
- Department of Medicine; Virginia Commonwealth University; Richmond; VA; USA
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203
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Merli M, Calicchia A, Ruffa A, Pellicori P, Riggio O, Giusto M, Gaudio C, Torromeo C. Cardiac dysfunction in cirrhosis is not associated with the severity of liver disease. Eur J Intern Med 2013; 24:172-6. [PMID: 22958907 DOI: 10.1016/j.ejim.2012.08.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/12/2012] [Accepted: 08/14/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cirrhotic cardiomiopathy is described as the presence of cardiac dysfunction in cirrhotic patients. The aim of the study was to investigate factors associated with cardiac dysfunction in cirrhotic patients. PATIENTS AND METHODS Seventy-four cirrhotic patients and twenty-six controls performed a conventional echocardiography and Tissue Doppler Imaging (TDI) for systolic and diastolic function. Results were analyzed by using the Guidelines of American Society of Echocardiography. RESULTS In patients with cirrhosis, left ventricular end-diastolic diameter was increased (p<0.001) , peak systolic velocities were decreased (11.3±2.7 vs 13.9±1.4cm/s; p<0.001) and left atrial volumes were increased (32.7±8.3 vs 24±8.5ml, p<0.001) as well as cardiac mass (90.6±23 vs 70.5±22g/m(2), p<0.001). Forty-seven cirrhotic patients (64%) showed diastolic dysfunction at rest: grade I in 37 and grade II in 10 patients. Systolic and/or diastolic dysfunction were not influenced by a more severe liver impairment. Diastolic dysfunction was more prevalent in patients with ascites vs those without (77% vs 56%; p=0.04). CONCLUSION A mild diastolic dysfunction at rest is frequent in cirrhotic patients but cardiac load conditions are confounding factors in this diagnosis. We did not identify an association between severity of liver disease and cardiac dysfunction.
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Affiliation(s)
- Manuela Merli
- Gastroenterologia, Dipartimento Medicina Clinica, Sapienza Università di Roma, Italy.
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Diastolic dysfunction in patients with end-stage liver disease is associated with development of heart failure early after liver transplantation. Transplantation 2012; 94:646-51. [PMID: 22918216 DOI: 10.1097/tp.0b013e31825f0f97] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation (LTx) is a life-saving treatment of end-stage liver disease. Cardiac complications including heart failure (HF) are among the leading causes of death after LTx. THE AIM The aim is to identify clinical and echocardiographic predictors of developing HF after LTx. METHODS Patients who underwent LTx at the University of Nebraska Medical Center (UNMC) between January 2001 and January 2009 and had echocardiographic study before and within 6 months after transplantation were identified. Patients with coronary artery disease (>70% lesion) were excluded. HF after LTx was defined by clinical signs, symptoms, radiographic evidence of pulmonary congestion, and echocardiographic evidence of left ventricular dysfunction (left ventricle ejection fraction <50%). RESULTS Among 107 patients (presented as mean age [SD], 55 [10] years; male, 70%) who met the inclusion criteria, 26 (24%) patients developed HF after LTx. The pre-LTx left ventricle ejection fraction did not differ between the HF (69 [7]) and the control groups (69 [7] vs. 67 [6], P=0.30). However, pre-LTx elevation of early mitral inflow velocity/mitral annular velocity (P=0.02), increased left atrial volume index (P=0.05), and lower mean arterial pressure (P=0.03) were predictors of HF after LTx in multivariate analysis. Early mitral inflow velocity/mitral annular velocity greater than 10 and left atrial volume index 40 mL/m2 or more were associated with a 3.4-fold (confidence interval, 1.2-9.4; P=0.017) and 2.9-fold (confidence interval, 1.1-7.5; P=0.03) increase in risk of development of HF after LTx, respectively. CONCLUSIONS This study suggests that elevated markers of diastolic dysfunction during pre-LTx echocardiographic evaluation are associated with an excess risk of HF and may predict post-LTx survival.
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206
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Liu L, Liu H, Nam SW, Lee SS. Protective effects of erythropoietin on cirrhotic cardiomyopathy in rats. Dig Liver Dis 2012; 44:1012-7. [PMID: 22835858 DOI: 10.1016/j.dld.2012.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 06/20/2012] [Accepted: 06/24/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Erythropoietin exerts cardioprotective effects. The present study aimed to investigate the therapeutic effects of erythropoietin on cirrhotic cardiomyopathy. MATERIALS AND METHODS Rats were divided into 5 groups: sham control; sham+ erythropoietin; bile duct ligation; bile duct ligation+erythropoietin; bile duct ligation+erythropoietin+anti-tumour necrosis factor alpha (TNFα) antibody and were studied 4 wk after surgery. Erythropoietin was administrated for 10 days before the study date. TNFα, erythropoietin receptor-1 expression and oxidative stress-related parameters were measured. In separate groups, isolated cardiomyocytes were subjected to contractile and relaxation studies. Cardiomyocyte cell line was used to test the direct effect of erythropoietin on nuclear factor (erythroid-derived 2)-like 2(Nrf2). RESULTS Erythropoietin receptor-1, TNFα and oxidative modified proteins were significantly increased (p<0.01), and the antioxidant regulator Nrf2 transcription decreased in cirrhotic hearts (p<0.01). Erythropoietin reversed these parameters. Maximal cardiac contractile and relaxation velocity was significantly decreased in cirrhotic cardiomyocytes. Erythropoietin significantly reversed these inhibitions. Anti-TNFα antibody significantly decreased cardiac TNFα content but did not further increase contractility. CONCLUSIONS TNFα and oxidative stress are involved in cardiac dysfunction in the cirrhotic heart. Erythropoietin significantly decreased TNFα and oxidative stress and reversed the impaired cardiac function.
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Affiliation(s)
- Li Liu
- Liver Unit, University of Calgary, Calgary, AB T2N 4N1, Canada
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207
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Nandhakumar A, McCluskey SA, Srinivas C, Chandy TT. Liver transplantation: Advances and perioperative care. Indian J Anaesth 2012; 56:326-35. [PMID: 23087453 PMCID: PMC3469909 DOI: 10.4103/0019-5049.100812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Liver transplantation is one of the treatments for many-life threatening liver diseases. Numerous advances in liver transplant surgery, anaesthesia and perioperative care have allowed for an increasing number of these procedures. The purpose of this review is to consider some of the important advances in perioperative care of liver transplant patients such as pre-operative evaluation, intraoperative monitoring and management and early extubation. A PubMed and EMBASE search of terms “Anaesthesia” and “Liver Transplantation” were performed with filters of articles in “English”, “Adult” and relevant recent publications of randomised control trial, editorial, systemic review and non-systemic review were selected and synthesized according to the author's personal and professional perspective in the field of liver transplantation and anaesthesia. The article outlines strategies in organ preservation, training and transplant database for further research.
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Affiliation(s)
- Amar Nandhakumar
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, ON M5G 2C4, Canada
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208
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Tachotti Pires L, Cardoso Curiati M, Vissoci Reiche F, Silvestre O, Mangini S, Carballo Afonso R, Ferraz-Neto BH, Bacal F. Stress-Induced Cardiomyopathy (Takotsubo Cardiomyopathy) After Liver Transplantation—Report of Two Cases. Transplant Proc 2012; 44:2497-500. [DOI: 10.1016/j.transproceed.2012.07.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Theocharidou E, Krag A, Bendtsen F, Møller S, Burroughs AK. Cardiac dysfunction in cirrhosis - does adrenal function play a role? A hypothesis. Liver Int 2012; 32:1327-32. [PMID: 22292920 DOI: 10.1111/j.1478-3231.2011.02751.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/20/2011] [Indexed: 12/12/2022]
Abstract
Cirrhotic cardiomyopathy (CCM), a condition of unknown pathogenesis, is characterized by suboptimal ventricular contractile response to stress, diastolic dysfunction and QT interval prolongation. It is most often found in patients with advanced cirrhosis. It is clinically relevant during stressful conditions, such as sepsis, bleeding and surgery. CCM reverses after liver transplantation and potentially has a role in the pathogenesis of hepatorenal syndrome. In adrenal insufficiency (AI), cardiac dysfunction is a feature with low ejection fraction, decreased left ventricular chamber size and electrocardiographic abnormalities, including QT interval prolongation. With optimal diagnostic tests, AI is present in approximately 10% of patients with cirrhosis, particularly in those with advanced disease. Down-regulation and decreased number of beta-adrenergic receptors, and high catecholamine levels are common to both cardiac conditions. Thus, AI may play a role in CCM. Steroid replacement therapy reverses cardiac changes in AI, and may do so for CCM, with important therapeutic implications; this needs formal evaluation.
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Affiliation(s)
- Eleni Theocharidou
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Royal Free Hampstead NHS Trust and UCL, London, UK
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210
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McCabe N, Farris AB, Hon H, Ford R, Book WM. Hepatocellular carcinoma in an adult with repaired tetralogy of fallot. CONGENIT HEART DIS 2012; 8:E139-44. [PMID: 22897884 DOI: 10.1111/j.1747-0803.2012.00700.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2012] [Indexed: 12/13/2022]
Abstract
Liver fibrosis is a growing concern among adults with congenital heart disease, particularly for those who have undergone a Fontan operation. Liver fibrosis leads to cirrhosis, a precursor of hepatocellular carcinoma. A few cases of hepatocellular carcinoma in patients with prior palliative surgery for congenital heart disease have been identified in the literature. The current case reports the first known case of hepatocellular carcinoma in a 45-year-old male with repaired tetralogy of Fallot.
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Affiliation(s)
- Nancy McCabe
- Nell Hodgson Woodruff School, Department of Medicine, Emory University, Atlanta, Ga, USA
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211
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Owens AT, Jessup M. The Year in Heart Failure. J Am Coll Cardiol 2012; 60:359-68. [DOI: 10.1016/j.jacc.2012.01.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 12/20/2011] [Accepted: 01/21/2012] [Indexed: 01/11/2023]
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Tarquini R, Mazzoccoli G, Fusi F, Laffi G, Gensini GF, Romano SM. Non invasive continuous hemodynamic evaluation of cirrhotic patients after postural challenge. World J Hepatol 2012; 4:149-53. [PMID: 22567187 PMCID: PMC3345539 DOI: 10.4254/wjh.v4.i4.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 11/08/2011] [Accepted: 04/24/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To assess whether Most Care is able to detect the cardiovascular alterations in response to physiological stress (posture). METHODS Non invasive hemodynamic was assessed in 26 cirrhotic patients compared to healthy subjects, both in the supine and standing positions. RESULTS In baseline conditions, when compared to healthy subjects, cirrhotic patients showed significantly lower values of dicrotic and diastolic pressures and systemic vascular resistance. While in the standing position, cirrhotic patients showed higher values of cardiac index, stroke volume index and cardiac cycle efficiency. When returning to the supine position, cirrhotic patients exhibited lower values of dicrotic and diastolic pressures and systemic vascular resistance in the presence of higher values of cardiac index, stroke volume index and cardiac cycle efficiency. CONCLUSION Most Care proved to be able to detect cardiovascular abnormalities bedside in the resting state and after postural challenge in cirrhotic patients.
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Affiliation(s)
- Roberto Tarquini
- Roberto Tarquini, Fulvio Fusi, Giacomo Laffi, Department of Internal Medicine, School of Medicine, 50134 Florence, Italy
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213
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Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012. [PMID: 22527060 DOI: 10.1007/s00134-012-2531-2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the incidence of and risk factors for adverse cardiac events during catecholamine vasopressor therapy in surgical intensive care unit patients with cardiovascular failure. METHODS The occurrence of any of seven predefined adverse cardiac events (prolonged elevated heart rate, tachyarrhythmia, myocardial cell damage, acute cardiac arrest or death, pulmonary hypertension-induced right heart dysfunction, reduction of systemic blood flow) was prospectively recorded during catecholamine vasopressor therapy lasting at least 12 h. RESULTS Fifty-four of 112 study patients developed a total of 114 adverse cardiac events, an incidence of 48.2 % (95 % CI, 38.8-57.6 %). New-onset tachyarrhythmia (49.1 %), prolonged elevated heart rate (23.7 %), and myocardial cell damage (17.5 %) occurred most frequently. Aside from chronic liver diseases, factors independently associated with the occurrence of adverse cardiac events included need for renal replacement therapy, disease severity (assessed by the Simplified Acute Physiology Score II), number of catecholamine vasopressors (OR, 1.73; 95 % CI, 1.08-2.77; p = 0.02) and duration of catecholamine vasopressor therapy (OR, 1.01; 95 % CI, 1-1.01; p = 0.002). Patients developing adverse cardiac events were on catecholamine vasopressors (p < 0.001) and mechanical ventilation (p < 0.001) for longer and had longer intensive care unit stays (p < 0.001) and greater mortality (25.9 vs. 1.7 %; p < 0.001) than patients who did not. CONCLUSIONS Adverse cardiac events occurred in 48.2 % of surgical intensive care unit patients with cardiovascular failure and were related to morbidity and mortality. The extent and duration of catecholamine vasopressor therapy were independently associated with and may contribute to the pathogenesis of adverse cardiac events.
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214
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Schmittinger CA, Torgersen C, Luckner G, Schröder DCH, Lorenz I, Dünser MW. Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012; 38:950-8. [PMID: 22527060 DOI: 10.1007/s00134-012-2531-2] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 03/05/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the incidence of and risk factors for adverse cardiac events during catecholamine vasopressor therapy in surgical intensive care unit patients with cardiovascular failure. METHODS The occurrence of any of seven predefined adverse cardiac events (prolonged elevated heart rate, tachyarrhythmia, myocardial cell damage, acute cardiac arrest or death, pulmonary hypertension-induced right heart dysfunction, reduction of systemic blood flow) was prospectively recorded during catecholamine vasopressor therapy lasting at least 12 h. RESULTS Fifty-four of 112 study patients developed a total of 114 adverse cardiac events, an incidence of 48.2 % (95 % CI, 38.8-57.6 %). New-onset tachyarrhythmia (49.1 %), prolonged elevated heart rate (23.7 %), and myocardial cell damage (17.5 %) occurred most frequently. Aside from chronic liver diseases, factors independently associated with the occurrence of adverse cardiac events included need for renal replacement therapy, disease severity (assessed by the Simplified Acute Physiology Score II), number of catecholamine vasopressors (OR, 1.73; 95 % CI, 1.08-2.77; p = 0.02) and duration of catecholamine vasopressor therapy (OR, 1.01; 95 % CI, 1-1.01; p = 0.002). Patients developing adverse cardiac events were on catecholamine vasopressors (p < 0.001) and mechanical ventilation (p < 0.001) for longer and had longer intensive care unit stays (p < 0.001) and greater mortality (25.9 vs. 1.7 %; p < 0.001) than patients who did not. CONCLUSIONS Adverse cardiac events occurred in 48.2 % of surgical intensive care unit patients with cardiovascular failure and were related to morbidity and mortality. The extent and duration of catecholamine vasopressor therapy were independently associated with and may contribute to the pathogenesis of adverse cardiac events.
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Affiliation(s)
- Christian A Schmittinger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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215
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Aller MA, Heras N, Blanco-Rivero J, Arias JI, Lahera V, Balfagón G, Arias J. Portal hypertensive cardiovascular pathology: the rescue of ancestral survival mechanisms? Clin Res Hepatol Gastroenterol 2012; 36:35-46. [PMID: 22264837 DOI: 10.1016/j.clinre.2011.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 07/26/2011] [Indexed: 02/04/2023]
Abstract
The portal system derives from the vitelline system, which is an extra-embryonic venous system. It could be suggested that this extraembryonic origin determines some of the characteristics attributed to portal hypertension, both compensated, i.e. prehepatic, and decompensated, i.e. fibrotic or cirrhotic. The experimental models most frequently used for studying both types of portal hypertension are portal vein ligation and common bile duct ligation in rats, respectively. We propose that in partial portal vein ligated rats, a low-grade inflammatory response, formed by the successive expression of three overlapping phenotypes - ischemia-reperfusion, vitellogenic-like and remodeling or gastrulation-like - is produced. The names of these inflammatory phenotypes developed in compensated portal hypertension are based on some metabolic similarities that can be established with the abovementioned phases of embryonic development. In bile-duct ligated rats, decompensation related to hepatic insufficiency would induce a high-grade inflammatory response. In this experimental model, the splanchnic interstitium, the mesenteric lymph and the peritoneal mesothelium seem to create an inflammatory axis that produces ascites. The functional comparison between the ascitic and the amniotic fluids would imply that, in the decompensated portal hypertensive syndrome, the abdominal mesothelium acquires properties of the amniotic membranes or amnion. In conclusion, the hypothetical comparison between the inflammatory portal hypertensive evolutive types and the evolutive phases of embryonic development could allow for translational research.
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Affiliation(s)
- Maria-Angeles Aller
- Department of Surgery I, School of Medicine, Complutense University of Madrid, Plaza de Ramon y Cajal s.n., 28040 Madrid, Spain
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216
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Harinstein ME, Raval Z, Gheorghiade M, Flaherty JD. Reply. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2011.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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217
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Abstract
Cardiac dysfunction in patients with cirrhosis and potential clinical implications have long been known, but the pathophysiology and potential targets for therapeutic intervention are still under investigation and are only now becoming understood. The pathophysiological changes result in systolic dysfunction, diastolic dysfunction, and electrophysiological changes. Here, we aim to review cirrhotic cardiomyopathy from a cellular and physiological model and how these patients develop overt heart failure in the setting of stress, such as infection, ascites, and procedures including transjugular intrahepatic portosystemic shunt, portocaval shunts, and orthotopic liver transplantation. We will also review the most current, although limited, available therapeutic modalities.
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218
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Pouriki S, Alexopoulou A, Chrysochoou C, Raftopoulos L, Papatheodoridis G, Stefanadis C, Pectasides D. Left ventricle enlargement and increased systolic velocity in the mitral valve are indirect markers of the hepatopulmonary syndrome. Liver Int 2011; 31:1388-94. [PMID: 21771264 DOI: 10.1111/j.1478-3231.2011.02591.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) has been associated with left atrial enlargement, but the presence of other markers of left and right diastolic and/or systolic cardiac dysfunction has not been clarified. We prospectively evaluated the possible associations between echocardiographical-Doppler findings and HPS. METHODS Seventy-nine cirrhotic patients without endogenous heart or pulmonary disease were included. HPS was diagnosed by the presence of increased arterial-alveolar-difference and intrapulmonary right-to-left shunt at contrast-enhanced transthoracic echocardiography. Echocardiographical systolic and diastolic indices, tissue Doppler imaging (TDI) of mitral and tricuspid annular motion and M-mode echocardiography measurements were recorded. RESULTS Hepatopulmonary syndrome was diagnosed in 12 (15.2%) patients. Patients with compared with those without HPS had significantly younger age, albumin levels and saturation of oxygen (SaO(2)) in an erect position, but higher left ventricular end diastolic diameter (LVEDD), ejection fraction, E-wave peak velocity of tricuspid valve, left atrial volume, TDI E wave (early diastolic period) at the right free wall/tricuspid annulus (cm/s) and TDI S wave (systolic) at the left lateral wall/mitral annulus (TDI Smv). In multivariate analysis, the presence of HPS was found to be independently associated with younger age (P=0.027), lower SaO(2) in an erect position (P=0.023), higher LVEDD (P=0.019) and higher TDI Smv (P=0.026). LVEDD and TDI Smv offered good diagnostic accuracy for HPS diagnosis (AUROC/c-statistic: 0.724 and 0.736 respectively). CONCLUSIONS We confirmed that in patients with cirrhosis, the development of HPS is associated with higher cardiac output and hyperdynamic circulation. Left ventricle enlargement and higher systolic velocity in the mitral valve represent satisfactory indirect markers of HPS.
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Affiliation(s)
- Sophia Pouriki
- Second Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Athens, Greece
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219
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Desai MS, Zainuer S, Kennedy C, Kearney D, Goss J, Karpen SJ. Cardiac structural and functional alterations in infants and children with biliary atresia, listed for liver transplantation. Gastroenterology 2011; 141:1264-72, 1272.e1-4. [PMID: 21762660 PMCID: PMC3740524 DOI: 10.1053/j.gastro.2011.06.082] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 06/17/2011] [Accepted: 06/29/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Cirrhotic liver diseases are associated with abnormalities in cardiac geometry and function in adults (cirrhotic cardiomyopathy) but rarely explored in cirrhotic infants or children. We proposed that features of cirrhotic cardiomyopathy are present in infants with cirrhosis due to biliary atresia (BA) as early as the time of evaluation for liver transplant and will correlate with mortality and postoperative morbidity. METHODS Two-dimensional echocardiography (2DE) of infants with BA (n=40; median age, 8 months), listed for transplantation at the Texas Children's Hospital from 2004 to 2010, were reviewed and compared with age- and sex-matched infants without cardiac or liver disease (controls). Length of stay and correlation with 2DE results were assessed. RESULTS Compared with controls, children with BA had significant increases in multiple 2DE parameters, notably left ventricle wall thickness (23% increase), left ventricular (LV) mass indexed to body surface area (51% increase), and LV shortening fraction (8% increase). Overall, features of cirrhotic cardiomyopathy were observed in most infants (29/40; 72%); 17 had hyperdynamic contractility, and 24 had altered LV geometry. After liver transplantation (33), infants with abnormal 2DE results had longer stays in the intensive care unit (median, 6 vs 4 days) and the hospital (21 vs 11 days) compared with infants who had normal 2DE reports. On univariate analysis, the length of hospital stay correlated with LV mass index. CONCLUSIONS Cardiomyopathy is a prevalent condition in infants with end-stage cirrhotic liver disease due to BA (>70%). This underrecognized condition likely contributes to the prolongation of posttransplant hospitalization.
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Affiliation(s)
- Moreshwar S. Desai
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston TX.
| | - Shabier Zainuer
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston TX.
| | - Curtis Kennedy
- Section of Pediatric Critical Care, Baylor College of Medicine, Houston TX.
| | - Debra Kearney
- Department of Pathology, Baylor College of Medicine, Houston TX.
| | - John Goss
- Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.
| | - Saul J. Karpen
- Texas Children’s Liver Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA.
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Abstract
OBJECTIVES To review the management of complications related to end-stage liver disease in the intensive care unit. The goal of this review is to address topics important to the practicing physician. DATA SOURCES We performed an organ system-based PubMed literature review focusing on the diagnosis and treatment of critical complications of end-stage liver disease. DATA SYNTHESIS AND FINDINGS: When available, preferential consideration was given to randomized controlled trials. In the absence of trials, observational and retrospective studies and consensus opinions were included. We present our recommendations for the neurologic, cardiovascular, pulmonary, gastrointestinal, renal, and infectious complications of end-stage liver disease. CONCLUSIONS Complications related to end-stage liver disease have significant morbidity and mortality. Management of these complications in the intensive care unit requires awareness and expertise among physicians from a wide variety of fields.
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Aljaroudi W, Aggarwal H, Iqbal F, Heo J, Iskandrian AE. Left ventricular dyssynchrony in patients with end-stage liver disease. J Nucl Cardiol 2011; 18:451-5. [PMID: 21479756 DOI: 10.1007/s12350-010-9332-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 12/13/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limited published data suggested that patients with end-stage liver disease (ESLD) might have "cirrhotic cardiomyopathy," which could have an earlier stage manifested by mechanical dyssynchrony before left ventricular (LV) dysfunction. METHODS AND RESULTS We studied consecutive patients with ESLD who had a stress-gated Tc-99m sestamibi myocardial perfusion imaging between 2008 and 2010 prior to liver transplant. Patients with LVEF < 50%, abnormal perfusion, or QRS ≥ 120 ms were excluded. Baseline demographics, co-morbidities, model for ESLD (MELD) score, LV volumes, mass, ejection fraction (EF), and dyssynchrony indices (standard deviation and bandwidth) were extracted. The phase indices were compared to a normal cohort. There were 179 patients with a mean age 53 ± 8 years, LVEF 72 ± 10%. Hepatitis C, non-alcoholic steatohepatitis, and alcohol abuse were the most common cause of liver cirrhosis (40%, 18%, and 14%, respectively). Patients with ESLD had similar standard deviation (14 ± 8° vs 15 ± 6°, P = NS) and bandwidth (41 ± 25° vs 42 ± 14°, P = NS) to the normal cohort. Only four patients (2%) had a standard deviation >27° (mean + 2 SD of the control group). The phase standard deviations and bandwidth similar in patients with MELD scores of ≤10, 11-18, 19-24, and ≥25 (P = NS for both). There was no correlation between the MELD score and standard deviation or bandwidth (r = -0.044 and -0.068, respectively, P = NS for both). Also, there was no correlation between the QTc and dyssynchrony indices. After 1-year follow-up, 22 patients died (12%). The dyssynchrony indices were similar among those who died and those who survived. CONCLUSION Patients with ESLD and normal EF have no evidence for LV dyssynchrony.
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Affiliation(s)
- Wael Aljaroudi
- Division of Cardiovascular Medicine, Section of Cardiovascular Imaging, Cleveland Clinic, Mail Code J1-5, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kazankov K, Holland-Fischer P, Andersen NH, Torp P, Sloth E, Aagaard NK, Vilstrup H. Resting myocardial dysfunction in cirrhosis quantified by tissue Doppler imaging. Liver Int 2011; 31:534-40. [PMID: 21382164 DOI: 10.1111/j.1478-3231.2011.02468.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cirrhotic cardiomyopathy is described as latent cardiac failure. However, it remains to be investigated whether the myocardial dysfunction is present even at rest. AIMS The aim of the present study was to quantify left ventricular function at rest by means of tissue Doppler imaging in patients with cirrhosis and relate the findings to liver status and cirrhosis aetiology. METHODS Forty-four consecutive patients and 23 age-matched healthy controls were included. Conventional echocardiographic- and tissue Doppler-derived indices of systolic and diastolic function were obtained. Liver function was quantified by the galactose elimination capacity and clinical stage by the Child-Pugh and MELD scores. RESULTS Both systolic and diastolic myocardial functions were compromised in the patients at rest. Left ventricular ejection fraction (56.4 ± 6.1 vs. 59.9 ± 3.9%, P<0.02), mean peak systolic tissue velocity (4.6 ± 0.9 vs. 5.6 ± 0.7 cm/s, P<0.001) and mean systolic strain rate (-1.23 ± 0.19 vs. -1.5 ± 0.14/s, P<0.001) were all reduced in cirrhosis patients. Thirty-four patients (54%) had diastolic dysfunction, 11 had impaired diastolic relaxation pattern (25%), 12 had the more severe pseudonormal filling pattern (27%) and one had restrictive filling or severe diastolic dysfunction (2%). None of the echocardiographic findings were related to the cirrhosis aetiology. CONCLUSION Tissue Doppler imaging during rest detected substantial systolic and diastolic myocardial dysfunction in cirrhotic patients. This supports the existence of a distinct cirrhotic cardiomyopathy.
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Affiliation(s)
- Konstantin Kazankov
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, Skejby, Denmark.
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