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Almeida F, Sousa A. Cirrhotic cardiomyopathy: Pathogenesis, clinical features, diagnosis, treatment and prognosis. Rev Port Cardiol 2024; 43:203-212. [PMID: 38142819 DOI: 10.1016/j.repc.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/09/2023] [Accepted: 07/30/2023] [Indexed: 12/26/2023] Open
Abstract
Cardiac dysfunction among cirrhotic patients has long been recognized in the medical community. While it was originally believed to be a direct result of alcohol toxicity, in the last 30 years cirrhotic cardiomyopathy (CCM) has been described as a syndrome characterized by chronic cardiac dysfunction in cirrhotic patients in the absence of known cardiac disease, regardless of the etiology of cirrhosis. CCM occurs in about 60% of patients with cirrhosis and plays a critical role in disease progression and treatment outcomes. Due to its predominantly asymptomatic course, diagnosing CCM is challenging and requires a high index of suspicion and a multiparametric approach. Patients with CCM usually present with the following triad: impaired myocardial contractile response to exercise, inadequate ventricular relaxation, and electrophysiological abnormalities (notably prolonged QT interval). In recent years, research in this area has grown expeditiously and a new set of diagnostic criteria has been developed by the Cirrhotic Cardiomyopathy Consortium, to properly identify patients with CCM. Nevertheless, CCM is still largely unknown among clinicians, and a major part of its pathophysiology and treatment is yet to be understood. In the present work, we aim to compile and summarize the available data on the pathogenesis, clinical features, diagnosis, treatment, and prognosis of CCM.
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Affiliation(s)
| | - Alexandra Sousa
- Cardiology Department, Unidade Local de Saúde de Entre o Douro e Vouga, Santa Maria da Feira, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; RISE - Health Research Network, Porto, Portugal
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2
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Wang W, Dong L, Gao Y, Gao F, Wang Z, Ding M, Gu C, Li Z, Yin Y, Zhu M, Chen H, Li H, Qi X. Association of echocardiography-related parameters with the prognosis of decompensated cirrhosis: a retrospective cohort study. Curr Med Res Opin 2024; 40:613-620. [PMID: 38369940 DOI: 10.1080/03007995.2024.2319821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Cardiac morphology and function, which are conventionally evaluated by echocardiography, are often abnormal in decompensated cirrhosis. We aimed to evaluate the association of echocardiography-related parameters with prognosis in cirrhosis. METHODS This retrospective study included 104 decompensated cirrhotic patients, in whom cardiac structure and function were measured by echocardiography, including mitral inflow early diastolic velocity/mitral inflow late diastolic velocity (E/A), left atrium diameter, left ventricular end-diastolic dimension, interventricular septal thickness, left ventricular posterior wall thickness, right atrial transverse diameter, right atrial longitudinal diameter, right ventricular dimension (RVD), stroke volume, cardiac output, left ventricular ejection fraction, and fractional shortening. Cox regression and competing risk analyses and Kaplan-Meier and Nelson-Aalen cumulative risk curves were used to evaluate their associations with further decompensation and death in cirrhotic patients, if appropriate. RESULTS Lower RVD was a predictor of further decompensation in Cox regression (adjusted by Child-Pugh score: p = 0.138; adjusted by MELD score: p = 0.034) and competing risk analyses (p = 0.003), and RVD ≤17 mm was significantly associated with higher cumulative incidence of further decompensation in Kaplan-Meier (p = 0.002) and Nelson-Aalen cumulative risk curves (p = 0.002). E/A ≤ 0.8 was a significant predictor of death in Cox regression (adjusted by Child-Pugh score: p = 0.041; adjusted by MELD score: p = 0.045) and competing risk analyses (p = 0.024), and E/A ≤ 0.8 was significantly associated with higher cumulative incidence of death in Kaplan-Meier (p = 0.023) and Nelson-Aalen cumulative risk curves (p = 0.024). Other echocardiography-related parameters were not significantly associated with further decompensation or death. CONCLUSION RVD and E/A may be considered for the prognostic assessment of decompensated cirrhosis.
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Affiliation(s)
- Weiwei Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Liyan Dong
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Yue Gao
- Department of Ultrasound, General Hospital of Northern Theater Command, Shenyang, China
| | - Fangbo Gao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Zhongchao Wang
- Department of Congenital Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Min Ding
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Chunru Gu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Zhe Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Yue Yin
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Menghua Zhu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Hongxin Chen
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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3
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Burelle C, Clapatiuc V, Deschênes S, Cuillerier A, De Loof M, Higgins MÈ, Boël H, Daneault C, Chouinard B, Clavet MÉ, Tessier N, Croteau I, Chabot G, Martel C, Sirois MG, Lesage S, Burelle Y, Ruiz M. A genetic mouse model of lean-NAFLD unveils sexual dimorphism in the liver-heart axis. Commun Biol 2024; 7:356. [PMID: 38519536 PMCID: PMC10959946 DOI: 10.1038/s42003-024-06035-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
Lean patients with NAFLD may develop cardiac complications independently of pre-existent metabolic disruptions and comorbidities. To address the underlying mechanisms independent of the development of obesity, we used a murine model of hepatic mitochondrial deficiency. The liver-heart axis was studied as these mice develop microvesicular steatosis without obesity. Our results unveil a sex-dependent phenotypic remodeling beyond liver damage. Males, more than females, show fasting hypoglycemia and increased insulin sensitivity. They exhibit diastolic dysfunction, remodeling of the circulating lipoproteins and cardiac lipidome. Conversely, females do not manifest cardiac dysfunction but exhibit cardiometabolic impairments supported by impaired mitochondrial integrity and β-oxidation, remodeling of circulating lipoproteins and intracardiac accumulation of deleterious triglycerides. This study underscores metabolic defects in the liver resulting in significant sex-dependent cardiac abnormalities independent of obesity. This experimental model may prove useful to better understand the sex-related variability, notably in the heart, involved in the progression of lean-NAFLD.
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Affiliation(s)
- Charlotte Burelle
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Valentin Clapatiuc
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Sonia Deschênes
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Alexanne Cuillerier
- Faculty of Health Sciences and Medicine, University of Ottawa, Ottawa, OC, Canada
| | - Marine De Loof
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | | | - Hugues Boël
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | | | | | | | - Nolwenn Tessier
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | | | - Geneviève Chabot
- Research Center, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada
| | - Catherine Martel
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Martin G Sirois
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Department of Physiology and Pharmacology, Université de Montréal, Montreal, QC, Canada
| | - Sylvie Lesage
- Research Center, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada
| | - Yan Burelle
- Faculty of Health Sciences and Medicine, University of Ottawa, Ottawa, OC, Canada
| | - Matthieu Ruiz
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.
- Department of Nutrition, Université de Montréal, Montreal, QC, Canada.
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Arcas-Bellas JJ, Siljeström R, Sánchez C, González A, García-Fernández J. Use of Transesophageal Echocardiography During Orthotopic Liver Transplantation: Simplifying the Procedure. Transplant Direct 2024; 10:e1564. [PMID: 38274476 PMCID: PMC10810591 DOI: 10.1097/txd.0000000000001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 01/27/2024] Open
Abstract
The intraoperative management of patients undergoing orthotopic liver transplantation (OLT) is influenced by the cardiovascular manifestations typically found in the context of end-stage liver disease, by the presence of concomitant cardiovascular disease, and by the significant hemodynamic changes that occur during surgery. Hypotension and intraoperative blood pressure fluctuations during OLT are associated with liver graft dysfunction, acute kidney failure, and increased risk of 30-d mortality. Patients also frequently present hemodynamic instability due to various causes, including cardiac arrest. Recent evidence has shown transesophageal echocardiography (TEE) to be a useful minimally invasive monitoring tool in patients undergoing OLT that gives valuable real-time information on biventricular function and volume status and can help to detect OLT-specific complications or situations. TEE also facilitates rapid diagnosis of life-threatening conditions in each stage of OLT, which is difficult to identify with other types of monitoring commonly used. Although there is no consensus on the best approach to intraoperative monitoring in these patients, intraoperative TEE is safe and useful and should be recommended during OLT, according to experts, for assessing hemodynamic changes, identifying possible complications, and guiding treatment with fluids and inotropes to achieve optimal patient care.
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Affiliation(s)
- José J. Arcas-Bellas
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Roberto Siljeström
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Cristina Sánchez
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Ana González
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Javier García-Fernández
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
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Møller S, Wiese S, Barløse M, Hove JD. How non-alcoholic fatty liver disease and cirrhosis affect the heart. Hepatol Int 2023; 17:1333-1349. [PMID: 37770804 DOI: 10.1007/s12072-023-10590-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023]
Abstract
Liver diseases affect the heart and the vascular system. Cardiovascular complications appear to be a leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD) and cirrhosis. The predominant histological changes in the liver range from steatosis to fibrosis to cirrhosis, which can each affect the cardiovascular system differently. Patients with cirrhotic cardiomyopathy (CCM) and NAFLD are at increased risk of impaired systolic and diastolic dysfunction and for suffering major cardiovascular events. However, the pathophysiological mechanisms behind these risks differ depending on the nature of the liver disease. Accurate assessment of symptoms by contemporary diagnostic modalities is essential for identifying patients at risk, for evaluating candidates for treatment, and prior to any invasive procedures. This review explores current perspectives within this field.
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Affiliation(s)
- Søren Møller
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Signe Wiese
- Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Mads Barløse
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark
| | - Jens D Hove
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Hvidovre Hospital, Hvidovre, Denmark
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Papadopoulos VP, Mimidis K. Corrected QT interval in cirrhosis: A systematic review and meta-analysis. World J Hepatol 2023; 15:1060-1083. [PMID: 37900213 PMCID: PMC10600695 DOI: 10.4254/wjh.v15.i9.1060] [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: 07/16/2023] [Revised: 08/13/2023] [Accepted: 08/29/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Corrected QT (QTc) interval is prolonged in patients with liver cirrhosis and has been proposed to correlate with the severity of the disease. However, the effects of sex, age, severity, and etiology of cirrhosis on QTc have not been elucidated. At the same time, the role of treatment, acute illness, and liver transplantation (Tx) remains largely unknown. AIM To determine the mean QTc in patients with cirrhosis, assess whether QTc is prolonged in patients with cirrhosis, and investigate whether QTc is affected by factors such as sex, age, severity, etiology, treatment, acute illness, and liver Tx. METHODS In the present systematic review and meta-analysis, the searching protocol "{[QTc] OR [QT interval] OR [QT-interval] OR [Q-T syndrome]} AND {[cirrhosis] OR [Child-Pugh] OR [MELD]}" was applied in PubMed, EMBASE, and Google Scholar databases to identify studies that reported QTc in patients with cirrhosis and published after 1998. Seventy-three studies were considered eligible. Data concerning first author, year of publication, type of study, method used, sample size, mean age, female ratio, alcoholic etiology of cirrhosis ratio, Child-Pugh A/B/C ratio, mean model for end-stage liver disease (MELD) score, treatment with β-blockers, episode of acute gastrointestinal bleeding, formula for QT correction, mean pulse rate, QTc in patients with cirrhosis and controls, and QTc according to etiology of cirrhosis, sex, Child-Pugh stage, MELD score, and liver Tx status (pre-Tx/post-Tx) were retrieved. The Newcastle-Ottawa quality assessment scale appraised the quality of the eligible studies. Effect estimates, expressed as proportions or standardized mean differences, were combined using the random-effects, generic inverse variance method of DerSimonian and Laird. Subgroup, sensitivity analysis, and meta-regressions were applied to assess heterogeneity. The study has been registered in the PROSPERO database (CRD42023416595). RESULTS QTc combined mean in patients with cirrhosis was 444.8 ms [95% confidence interval (CI): 440.4-449.2; P < 0.001 when compared with the upper normal limit of 440 ms], presenting high heterogeneity (I2 = 97.5%; 95%CI: 97.2%-97.8%); both Egger's and Begg's tests showed non-significance. QTc was elongated in patients with cirrhosis compared with controls (P < 0.001). QTc was longer in patients with Child-Pugh C cirrhosis when compared with Child-Pugh B and A (P < 0.001); Child-Pugh B patients presented longer QTc when compared with Child-Pugh A patients (P = 0.003). The MELD score was higher in patients with cirrhosis with QTc > 440 ms when compared with QTc ≤ 440 ms (P < 0.001). No correlation of QTc with age (P = 0.693), sex (P = 0.753), or etiology (P = 0.418) was detected. β-blockers shortened QTc (P< 0.001). QTc was prolonged during acute gastrointestinal bleeding (P = 0.020). Tx tended to improve QTc (P < 0.001). No other sources of QTc heterogeneity were revealed. CONCLUSION QTc is prolonged in cirrhosis independently of sex, age, and etiology but is correlated with severity and affected by β-blockers and acute gastrointestinal bleeding. QTc is improved after liver Tx.
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Affiliation(s)
| | - Konstantinos Mimidis
- First Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis 68100, Greece
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7
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Ali SA, Arman HE, Shamseddeen H, Elsner N, Elsemesmani H, Johnson S, Zenisek J, Khemka A, Jarori U, Patidar KR, Orman E, Kubal C, Frick K. Cirrhotic cardiomyopathy: Predictors of major adverse cardiac events and assessment of reversibility after liver transplant. J Cardiol 2023; 82:113-121. [PMID: 37085028 DOI: 10.1016/j.jjcc.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/01/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Major adverse cardiac events (MACE) are a leading cause of morbidity and mortality after orthotopic liver transplantation (OLT). Cirrhotic cardiomyopathy (CCM), initially described in 2005 and revised in 2019, is a source of MACE in patients after OLT. We sought to identify CCM-related predictors of MACE at one-year follow-up after OLT and assess for reversibility of CCM post-OLT. METHODS This is a retrospective study of adult patients who underwent OLT between 2009 and 2019. All patients had transthoracic echocardiography pre-and post-OLT. Patients with a left ventricular ejection fraction <50 % pre-OLT were excluded. MACE was defined as death, myocardial infarction, congestive heart failure hospitalization, or cardiac arrest. RESULTS In total, 131 patients were included in this study, of whom 103 and 23 patients met the 2005 and 2019 criteria, respectively. During the follow-up period, 42 patients had MACE and these patients were more likely to have ascites (p = 0.003), hepatorenal syndrome (p = 0.019), and CCM per 2005 criteria (p = 0.023). There were no significant differences between pre-OLT CCM per 2019 criteria (19 % vs 17 %, p = 0.758) or MELD-Na score (21.24 vs 19.40, p = 0.166) for MACE post-OLT. Per the 2005 criteria, 35 of 103 patients recovered and these patients were less likely to have MACE post-OLT (p = 0.012). Per the 2019 criteria, 13 of 23 patients recovered post-OLT but this low number precluded further statistics. CONCLUSION The 2005 Montreal criteria for CCM were an independent predictor of MACE at one-year follow-up post-OLT while the 2019 CCC criteria for CCM were not. In addition, the 2005 Montreal criteria were more prevalent when compared to 2019 CCC criteria. Finally, the 2005 Montreal criteria were reversible post-OLT 34 % of the time compared to the 2019 CCC criteria which were reversible 57 % of the time.
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Affiliation(s)
- Saad A Ali
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Huseyin E Arman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hani Shamseddeen
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nathaniel Elsner
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hussein Elsemesmani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean Johnson
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joseph Zenisek
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abhishek Khemka
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Upasana Jarori
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar Kubal
- Division of Organ Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kyle Frick
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
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Bi S, Jiang Y, Zhao W, Niu X, Liu X, Jing X. The predictive value of revised diastolic dysfunction in outcomes of liver transplantation: A propensity score matching analysis. Front Surg 2023; 9:1072908. [PMID: 36684235 PMCID: PMC9852983 DOI: 10.3389/fsurg.2022.1072908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Background Diastolic dysfunction (DD), one of the earliest signs of cirrhotic cardiomyopathy (CCM), is included in the revised 2019 CCM criteria. Nonetheless, relevant research regarding the effects of revised DD on post-liver transplantation (LT) outcomes remains limited. Methods This retrospective study enrolled patients who underwent LT for decompensated cirrhosis, from January 2018 to March 2021. Patients were divided into DD and non-DD groups. Clinical data were collected. Patients were followed up with, for at least 1 year post-LT; cardiovascular adverse events (AEs) and survival status were recorded. Risk factors were identified using 1:2 propensity score matching (PSM), after adjusting for confounding factors. The caliper value was set to 0.02. Results Of 231 patients, 153 were diagnosed with DD (male, 81.8%; mean age, 51.5 ± 9.5 years). Nineteen patients with DD died within 1 year, post-LT. After PSM, 97 and 60 patients were diagnosed with and without DD, respectively. Patients with DD had longer intensive care unit (ICU) stays, higher perioperative cardiovascular AEs, and higher mortality rates than those without DD. In a multivariate analysis, interventricular septum (IVS), left atrial volume index (LAVI), and potassium levels were independent prognostic factors of perioperative cardiovascular AEs, while a decreased early diastolic mitral annular tissue velocity (e'), increased neutrophil-to-lymphocyte ratio (NLR) and tumor markers were predictors of mortality within 1 year post-LT after PSM (P < 0.05). Conclusion Cardiac DD may contribute to perioperative cardiovascular AEs and mortality post-LT. Clinicians should be aware of decompensated cirrhosis in patients with DD.
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Affiliation(s)
- Shenghua Bi
- Gastroenterology Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yueping Jiang
- Gastroenterology Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenjun Zhao
- Gastroenterology Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyan Niu
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuechun Liu
- Gastroenterology Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xue Jing
- Gastroenterology Department, The Affiliated Hospital of Qingdao University, Qingdao, China,Correspondence: Xue Jing
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Vetrugno L, Cherchi V, Zanini V, Cotrozzi S, Ventin M, Terrosu G, Baccarani U, Bove T. Association between preoperative diastolic dysfunction and early allograft dysfunction after orthotopic liver transplantation: An observational study. Echocardiography 2022; 39:561-567. [PMID: 35224775 DOI: 10.1111/echo.15328] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To investigate the association between the grade of diastolic dysfunction (DD) and the occurrence of early allograft dysfunction (EAD) in liver transplant patients following the new 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) guidelines. METHODS From January 2015 to December 2019, we retrospectively analyzed 83 patients who underwent orthotopic liver transplantation (OLTx) and their susceptibility to develop EAD according to the grade of preoperative DD. EAD was defined according to the criteria proposed by Olfhoff et al.; DD was defined with four parameters: E/A, e/e', Left Atrium volume, and Tricuspid Regurgitation velocity. RESULTS According to the ASE/EACVI guidelines grade II DD was detected in 20 patients (24.1%) undergoing OLTx. A statistically significant association was found between grade II DD and the occurrence of EAD (p-value < 0.003). The Kaplan-Meier analysis failed to find any significant difference between the survival probability, nevertheless at the end of a 90-day follow-up period, mortality showed a different trend in classes with more severe diastolic dysfunction. CONCLUSION According to the ASE/EACVI guidelines from 2016, patients with grade II DD seem to have a higher propensity to develop early allograft dysfunction EAD after OLTx. Our study advises a need for an urgent prospective multicenter study to elucidate the long-term outcomes of liver transplants patients with diastolic dysfunction.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral, and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
| | - Vittorio Cherchi
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Victor Zanini
- Department of Medicine, University of Udine, Udine, Italy
| | | | - Marco Ventin
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Giovanni Terrosu
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Umberto Baccarani
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Medicine, University of Udine, Udine, Italy
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10
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What's New in Cirrhotic Cardiomyopathy?-Review Article. J Pers Med 2021; 11:jpm11121285. [PMID: 34945757 PMCID: PMC8705028 DOI: 10.3390/jpm11121285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/21/2021] [Accepted: 11/25/2021] [Indexed: 01/16/2023] Open
Abstract
Cirrhotic cardiomyopathy (CCM) is a relatively new medical term. The constant development of novel diagnostic and clinical tools continuously delivers new data and findings about this broad disorder. The purpose of this review is to summarize current facts about CCM, identify gaps of knowledge, and indicate the direction in which to prepare an updated definition of CCM. We performed a review of the literature using scientific data sources with an emphasis on the latest findings. CCM is a clinical manifestation of disorders in the circulatory system in the course of portal hypertension. It is characterized by impaired left ventricular systolic and diastolic dysfunction, and electrophysiological abnormalities, especially QT interval prolongation. However, signs and symptoms reported by patients are non-specific and include reduced exercise tolerance, fatigue, peripheral oedema, and ascites. The disease usually remains asymptomatic with almost normal heart function, unless patients are exposed to stress or exertion. Unfortunately, due to the subclinical course, CCM is rarely recognized. Orthotopic liver transplantation (OLTx) seems to improve circulatory function although there is no consensus about its positive effect, with reported cases of heart failure onset after transplantation. Researchers indicate a careful pre-, peri-, and post-transplant cardiac assessment as a crucial point in detecting CCM and improving patients’ prognosis. There is also an urgent need to update the CCM definition and establish a diagnostic algorithm for early diagnosis of CCM as well as a specific treatment of this condition.
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11
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Razpotnik M, Bota S, Wimmer P, Hackl M, Lesnik G, Alber H, Peck-Radosavljevic M. The prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria. Liver Int 2021; 41:1058-1069. [PMID: 33342074 DOI: 10.1111/liv.14769] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 12/01/2020] [Accepted: 12/11/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Recently published criteria by 2019 Cirrhotic Cardiomyopathy Consortium set a lower threshold for reduced ejection fraction to diagnose systolic dysfunction in cirrhotic patients, and stress testing was replaced by echocardiography strain imaging. The criteria to diagnose diastolic dysfunction are in general concordant with the 2016 ASE/EACVI guidelines and differ considerably from the 2005 Montreal recommendations. We aimed to assess the prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria. METHODS Cirrhotic patients without another structural heart disease, arterial hypertension, portal vein thrombosis, HCC outside Milan criteria and presence of TIPS were enrolled. Speckle-tracking echocardiography was performed by EACVI certified investigators. RESULTS A total of 122 patients with cirrhosis fulfilled the inclusion criteria. Overall prevalence of cirrhotic cardiomyopathy was similar for 2005 Montreal and 2019 CCC: 67.2% vs 55.7% (P = .09); and significantly higher compared to 2009 ASE/EACVI criteria: 67.2% vs 35.2% (P < .0001) and 55.7% vs 35.2% (P = .002) respectively. Significantly more patients had diastolic dysfunction according to the 2005 Montreal compared to the 2009 ASE/EACVI and 2019 CCC criteria: 64.8% vs 32.8% (P < .0001) and 64.8% vs 7.4% (P < .0001). Systolic dysfunction was more frequently diagnosed according to 2019 CCC criteria compared to 2005 Montreal (53.3% vs 16.4%,P < .0001) or ASE/EACVI criteria (53.3% vs 4.9%,P < .0001). CONCLUSION Cirrhotic cardiomyopathy was present in around 60% of cirrhotic patients when applying the hepatological criteria. A considerably higher prevalence of systolic dysfunction according to the 2019 CCC criteria was observed. Long-term follow-up studies are needed to establish the validity of these criteria to predict clinically relevant outcomes.
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Affiliation(s)
- Marcel Razpotnik
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Simona Bota
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Philipp Wimmer
- Department of Internal Medicine and Cardiology (IMuK), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Michael Hackl
- Department of Internal Medicine and Cardiology (IMuK), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Gerald Lesnik
- Institut for diagnostic and interventional Radiology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Hannes Alber
- Department of Internal Medicine and Cardiology (IMuK), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
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12
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Cirrhotic Cardiomyopathy - A Veiled Threat. Cardiol Rev 2020; 30:80-89. [PMID: 33229904 DOI: 10.1097/crd.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.
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13
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Zardi EM, Giorgi C, Dobrina A, Vecile E, Zardi DM. Analogies and differences between cirrhotic cardiomyopathy and hepatopulmonary syndrome. Med Res Rev 2020; 41:739-753. [PMID: 33174630 DOI: 10.1002/med.21755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
Cirrhotic cardiomyopathy and hepatopulmonary syndrome are two quite frequent clinical entities that may complicate the course of liver cirrhosis. The common pathophysiological origin and the same clinical presentation make them difficult to compare. Cirrhotic cardiomyopathy and hepatopulmonary syndrome may start with dyspnea and breathlessness but the former is characterized by a chronic cardiac dysfunction and the latter by a defect of oxygenation due to pulmonary shunts formation. The focus is to differentiate them as soon as possible since the treatment is different until the patient undergoes liver transplant that is the real unique cure for them.
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Affiliation(s)
- Enrico Maria Zardi
- Internistic Ultrasound Service, Campus Bio-Medico University, Rome, Italy
| | - Chiara Giorgi
- Department of Radiology, S. Maria Della Misericordia Hospital, Urbino, Italy
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Elena Vecile
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Domenico Maria Zardi
- Interventional Cardiology Department of S. Andrea Hospital, University "La Sapienza", Rome, Italy
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14
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Understanding and managing cardiovascular outcomes in liver transplant recipients. Curr Opin Organ Transplant 2020; 24:148-155. [PMID: 30676402 DOI: 10.1097/mot.0000000000000614] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is a common cause of mortality after liver transplantation. The transplant community is focused on improving long-term survival. Understanding the prevalence of CVD in liver transplant recipients, precipitating factors as well as prevention and management strategies is essential to achieving this goal. RECENT FINDINGS CVD is the leading cause of death within the first year after transplant. Arrhythmia and heart failure are the most often cardiovascular morbidities in the first year after transplant which could be related to pretransplant diastolic dysfunction. Pretransplant diastolic dysfunction is reflective of presence of cirrhotic cardiomyopathy which is not as harmless as it was thought. Multiple cardiovascular risk prediction models have become available to aid management in liver transplant recipients. SUMMARY A comprehensive prevention and treatment strategy is critical to minimize cardiovascular morbidity and mortality after liver transplant. Weight management and metabolic syndrome control are cornerstones to any prevention and management strategy. Bariatric surgery is an underutilized tool in liver transplant recipients. Awareness of 'metabolic-friendly' immunosuppressive regimens should be sought. Strict adherence to the cardiology and endocrine society guidelines with regard to managing metabolic derangements post liver transplantation is instrumental for CVD prevention until transplant specific recommendations can be made.
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15
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Markin NW, Ringenberg KJ, Kassel CA, Walcutt CR, Chacon MM. 2018 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2019; 33:3239-3248. [DOI: 10.1053/j.jvca.2019.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022]
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16
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Stundiene I, Sarnelyte J, Norkute A, Aidietiene S, Liakina V, Masalaite L, Valantinas J. Liver cirrhosis and left ventricle diastolic dysfunction: Systematic review. World J Gastroenterol 2019; 25:4779-4795. [PMID: 31528101 PMCID: PMC6718042 DOI: 10.3748/wjg.v25.i32.4779] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/10/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver cirrhosis is a chronic hepatic disease which is associated with cardiovascular abnormalities. Hyperdynamic circulation in liver cirrhosis causes functional and structural cardiac alterations. The prevalence of left ventricle diastolic dysfunction (LVDD) in cirrhotic patients ranges from 25.7% to as high as 81.4% as reported in different studies. In several studies the severity of diastolic dysfunction (DD) correlated with a degree of liver failure and the rate of dysfunction was higher in patients with decompensated cirrhosis compared with compensated. Future directions of comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for these patients. AIM To clarify the correlation between the severity of liver cirrhosis and left ventricle diastolic dysfunction in the existing literature. METHODS Through January and February of 2019 at Vilnius University we conducted a systematic review of the global existing literature on the prevalence of left ventricle diastolic dysfunction in patients with liver cirrhosis. We searched for articles in PubMed, Medline and Web of science databases. Articles were selected by using adequate inclusion and exclusion criteria. Our interest was the outcome of likely correlation between the severity of cirrhosis [evaluated by Child-Pugh classes, Model For End-Stage Liver Disease (MELD) scores] and left ventricle diastolic dysfunction [classified according to American Society of Echocardiography (ASE) guidelines (2009, 2016)], as well as relative risk of dysfunction in cirrhotic patients. Subgroup analyses were performed to evaluate the ratio and grades of left ventricle diastolic dysfunction with respect to cirrhosis severity. RESULTS A total of 1149 articles and abstracts met the initial search criteria. Sixteen articles which met the predefined eligibility criteria were included in the final analysis. Overall, 1067 patients (out of them 723 men) with liver cirrhosis were evaluated for left ventricle diastolic dysfunction. In our systemic analysis we have found that 51.2% of cirrhotic patients had left ventricle diastolic dysfunction diagnosed and the grade 1 was the most prevalent (59.2%, P < 0.001) among them, the grade 3 had been rarely diagnosed - only 5.1%. The data about the prevalence of diastolic dysfunction in cirrhotic patients depending on Child-Pugh Classes was available from 5 studies (365 patients overall) and only in 1 research diastolic dysfunction was found being associated with severity of liver cirrhosis (P < 0.005). We established that diastolic dysfunction was diagnosed in 44.6% of Child-Pugh A class patients, in 62% of Child B class and in 63.3% of Child C patients (P = 0.028). The proportion of patients with higher diastolic dysfunction grades increases in more severe cirrhosis presentation (P < 0.001). There was no difference between mean MELD scores in patients with and without diastolic dysfunction and in different diastolic dysfunction groups. In all studies diastolic dysfunction was more frequent in patients with ascites. CONCLUSION This systemic analysis suggests that left ventricle diastolic dysfunction is an attribute of liver cirrhosis which has not received sufficient attention from clinicians so far. Future suggestions of a comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for these patients and give hint for better understanding of the left ventricle diastolic dysfunction pathogenesis in liver cirrhosis.
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Affiliation(s)
- Ieva Stundiene
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
| | - Julija Sarnelyte
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
| | - Ausma Norkute
- Vilnius University, Institute of Clinical Medicine, Clinic of Internal diseases, Family medicine and Oncology, Vilnius University, Vilnius LT-03101, Lithuania
| | - Sigita Aidietiene
- Vilnius University, Institute of Clinical Medicine, Clinic of Cardiology and Angiology, Vilnius University, Vilnius LT-03101, Lithuania
| | - Valentina Liakina
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
- Vilnius Gediminas Technical University, Faculty of Fundamental Sciences, Department of Chemistry and Bioengineering, Vilnius LT-10223, Lithuania
| | - Laura Masalaite
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
| | - Jonas Valantinas
- Vilnius University, Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius LT-03101, Lithuania
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17
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Główczyńska R, Galas M, Ołdakowska-Jedynak U, Peller M, Tomaniak M, Raszeja-Wyszomirska J, Milkiewicz P, Krawczyk M, Zieniewicz K, Opolski G. Pretransplant QT Interval: The Relationship with Severity and Etiology of Liver Disease and Prognostic Value After Liver Transplantation. Ann Transplant 2018; 23:622-630. [PMID: 30177675 PMCID: PMC6248058 DOI: 10.12659/aot.908769] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 04/09/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Prolonged QT interval is an integral part of the definition of cirrhotic cardiomyopathy. The aim of this study was to analyze the relationship between QT corrected (QTc) and the etiology and the severity of liver disease in relation to the complications of cirrhosis in candidates for orthotropic liver transplantation (OLTx). MATERIAL AND METHODS From 360 consecutive patients with end-stage liver disease (ESLD) consulted by a designated cardiologist, 160 patients underwent OLTx. The QTc was calculated according to 3 formulas in 151 ECG tracings with good quality. The severity of liver disease was assessed according to Child-Pugh classification and model for end-stage liver disease (MELD). This was a single-center study with register-based follow-up design. RESULTS Prolonged QTc over 440 ms was found in 51 subjects (33.8%), but none had prolonged QTc >500 ms. QTc corrected by Fridericia (F) formula was more suitable for patients with ESLD. We found no correlation between QTc interval and severity of liver disease. The QTc interval was higher in patients with alcoholic cirrhosis when compared to patients with viral hepatitis and ESLD of other etiologies. We observed a higher QTc interval in patients with gastroesophageal varices and encephalopathy. We did not notice any significant difference in the effect of the QTc interval on survival. CONCLUSIONS QTc interval might be associated with etiology and complication of ESLD. The prolonged QT interval is not associated with higher all-cause mortality after OLTx.
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Affiliation(s)
| | - Michalina Galas
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Urszula Ołdakowska-Jedynak
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Peller
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Tomaniak
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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18
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Lee SK, Song MJ, Kim SH, Ahn HJ. Cardiac diastolic dysfunction predicts poor prognosis in patients with decompensated liver cirrhosis. Clin Mol Hepatol 2018; 24:409-416. [PMID: 30145855 PMCID: PMC6313020 DOI: 10.3350/cmh.2018.0034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/29/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Left ventricular diastolic dysfunction (LVDD) is an early manifestation of cardiac dysfunction in patients with liver cirrhosis (LC). However, the effect of LVDD on survival has not been clarified, especially in decompensated LC. Methods We prospectively enrolled 70 patients with decompensated LC, including ascites or variceal bleeding, at Daejeon St. Mary’s Hospital from April 2013 to April 2015. The cardiac function of these patients was evaluated using 2D echocardiography with tissue Doppler imaging. The diagnosis of LVDD was based on the American Society of Echocardiography guidelines. The primary endpoint was overall survival. Results Forty-four patients (62.9%) had LVDD. During follow-up (22.3 months), 18 patients died (16 with LVDD and 2 without LVDD). The survival rate was significantly lower in patients with LVDD than in those without LVDD (31.1 months vs. 42.6 months, P=0.01). In a multivariate analysis, the Child-Pugh score and LVDD were independent predictors of survival. Moreover, patients with a ratio of early filling velocity to early diastolic mitral annular velocity (E/e’) ≥ 10 (LVDD grade 2) had lower survival than patients with E/e’ ratio < 10. Conclusions The presence of LVDD is associated with poor survival in patients with decompensated LC. Therefore, it may be important to monitor and closely follow LVDD patients.
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Affiliation(s)
- Soon Kyu Lee
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Myeong Jun Song
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Seok Hwan Kim
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hyo Jun Ahn
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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19
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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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20
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Ershoff B, Gordin J, Vorobiof G, Elashoff D, Steadman R, Scovotti J, Wray C. Improving the Prediction of Mortality in the High Model for End-Stage Liver Disease Score Liver Transplant Recipient: A Role for the Left Atrial Volume Index. Transplant Proc 2018; 50:1407-1412. [DOI: 10.1016/j.transproceed.2018.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/01/2018] [Indexed: 01/12/2023]
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21
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Møller S, Bendtsen F. The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis. Liver Int 2018; 38:570-580. [PMID: 28921803 DOI: 10.1111/liv.13589] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/11/2017] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis and portal hypertension often develop complications from a variety of organ systems leading to a multiple organ failure. The combination of liver failure and portal hypertension results in a hyperdynamic circulatory state partly owing to simultaneous splanchnic and peripheral arterial vasodilatation. Increases in circulatory vasodilators are believed to be due to portosystemic shunting and bacterial translocation leading to redistribution of the blood volume with central hypovolemia. Portal hypertension per se and increased splanchnic blood flow are mainly responsible for the development and perpetuation of the hyperdynamic circulation and the associated changes in cardiovascular function with development of cirrhotic cardiomyopathy, autonomic dysfunction and renal dysfunction as part of a cardiorenal syndrome. Several of the cardiovascular changes are reversible after liver transplantation and point to the pathophysiological significance of portal hypertension. In this paper, we aimed to review current knowledge on the pathophysiology of arterial vasodilatation and the hyperdynamic circulation in cirrhosis.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Faculty of Health Sciences, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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22
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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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23
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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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24
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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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Vallabhajosyula S, Gillespie SM, Barbara DW, Anavekar NS, Pulido JN. Impact of New-Onset Left Ventricular Dysfunction on Outcomes in Mechanically Ventilated Patients With Severe Sepsis and Septic Shock. J Intensive Care Med 2016; 33:680-686. [PMID: 28553776 DOI: 10.1177/0885066616684774] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND: Left ventricular systolic dysfunction (LVSD) and LV diastolic dysfunction (LVDD) are commonly seen in severe sepsis and septic shock; however, their role in patients with concurrent invasive mechanical ventilation (IMV) is less well defined. METHODS: This was a prospective observational study on all patients admitted to all the intensive care units (ICUs) at Mayo Clinic, Rochester from August 2007 to January 2009. All adult patients with severe sepsis and septic shock and concurrent IMV without prior heart failure underwent transthoracic echocardiography within 24 hours. Patients with active pregnancy, prior congenital or valvular heart disease, and prosthetic cardiac valves were excluded. Left ventricular systolic dysfunction was defined as LV ejection fraction (LVEF) <50% and LVDD as E/e' >15. Primary outcome was hospital mortality, and secondary outcomes included IMV duration, ICU length of stay (LOS), and total LOS. Two-tailed P value of <.05 was considered statistically significant. RESULTS: In a total of 106 patients, 58 (54.7%) met our inclusion criteria, with 17 (29.3%), 11 (19.0%), and 5 (8.6%) having LVSD, LVDD, and both, respectively. The cohorts with and without LVSD and LVDD did not differ significantly in their baseline characteristics and laboratory and ventilatory parameters. Compared to those without LVSD, patients with LVSD had higher LV end-systolic diameters but were not different in their left atrial diameters or E/e' ratio. Patients with LVDD had a higher E velocity and E/e' ratio compared to those without LVDD. Hospital mortality was not different in patients with and without LVSD (8 [47%] vs 21 [51%], P = 1.00) and LVDD (8 [73%] vs 21 [45%], P = .18). Secondary outcomes were not different between the 2 groups. CONCLUSION: Left ventricular systolic or diastolic dysfunction did not influence in-hospital outcomes in patients with severe sepsis and septic shock and concurrent IMV.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,2 Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Shane M Gillespie
- 3 Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - David W Barbara
- 3 Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Nandan S Anavekar
- 4 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,5 Division of Cardiac Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Juan N Pulido
- 6 Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Swedish Heart and Vascular Institute, Seattle, WA, USA
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Li YJ, Lei X, Yin H, Bai XL, Yan WT, Yang GM, Gui LL, Tan HB. Cirrhotic cardiomyopathy: Basic and clinical research. Shijie Huaren Xiaohua Zazhi 2016; 24:3846-3852. [DOI: 10.11569/wcjd.v24.i27.3846] [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] [Indexed: 02/06/2023] Open
Abstract
Cirrhotic cardiomyopathy (CCM) is a common complication of liver cirrhosis. Recent research found that a blunted inotropic and chronotropic response to stress, systolic and diastolic dysfunctions and prolongation of the QT interval are major reasons for the development of cardiovascular events under stress conditions in CCM patients. Myocardial apoptosis, abnormalities of adrenergic transduction pathways, gaseous signal molecule imbalance and derangement of various ion channels are involved in the development of CCM. The combination of measurement of BNP, H2S, electrocardiogram and echocardiography (resting and stress) is' helpful in the diagnosis of CCM. Liver transplantation is the only proven treatment with specific effect on CCM. Monitoring of cardiac function and timely treatment in case of severe trauma and infection are effective measures for preventing cardiovascular events. Only aldosterone antagonists have certain effects on CCM. The clinical efficacy of TCM therapy needs to be verified in future studies. New agents, targeting its pathogenic mechanisms, such as supplementing exogenous hydrogen sulfide, may play a role in patients who cannot undergo liver transplantation.
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