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Gananandan K, Wiese S, Møller S, Mookerjee RP. Cardiac dysfunction in patients with cirrhosis and acute decompensation. Liver Int 2024; 44:1832-1841. [PMID: 38712826 DOI: 10.1111/liv.15896] [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: 01/22/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
The prevalence of cirrhotic cardiomyopathy (CCM) has been reported as high as 60%-70% in patients with liver cirrhosis and is associated with various negative outcomes. There has been a growing understanding of CCM over recent years. Indeed, the development of imaging techniques has enabled new diagnostic criteria to be proposed by the Cirrhotic Cardiomyopathy Consortium. However, important unanswered questions remain over pathophysiological mechanisms, optimal diagnostic modalities and potential treatment options. While there has been an increasing volume of literature evaluating CCM, there is a lack of clarity on its implications in acute decompensation, acute-on-chronic liver failure and following interventions such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. This review aims to summarise the literature in these challenging domains and suggest where future research should focus. We conclude that systemic inflammation and structural myocardial changes are likely to be crucial in the pathophysiology of the disease, but the relative contribution of different components remains elusive. Furthermore, future studies need to use standardised diagnostic criteria for CCM as well as incorporate newer imaging techniques assessing both myocardial structure and function. Finally, while specific treatments are currently lacking, therapeutics targeting systemic inflammation, microbial dysbiosis and bacterial translocation are promising targets and warrant further research.
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Affiliation(s)
- Kohilan Gananandan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Signe Wiese
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Gastroenterology Unit, Medical Division, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Oyelade T, Moore KP, Mani AR. Physiological network approach to prognosis in cirrhosis: A shifting paradigm. Physiol Rep 2024; 12:e16133. [PMID: 38961593 PMCID: PMC11222171 DOI: 10.14814/phy2.16133] [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: 04/30/2024] [Revised: 06/12/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024] Open
Abstract
Decompensated liver disease is complicated by multi-organ failure and poor prognosis. The prognosis of patients with liver failure often dictates clinical management. Current prognostic models have focused on biomarkers considered as individual isolated units. Network physiology assesses the interactions among multiple physiological systems in health and disease irrespective of anatomical connectivity and defines the influence or dependence of one organ system on another. Indeed, recent applications of network mapping methods to patient data have shown improved prediction of response to therapy or prognosis in cirrhosis. Initially, different physical markers have been used to assess physiological coupling in cirrhosis including heart rate variability, heart rate turbulence, and skin temperature variability measures. Further, the parenclitic network analysis was recently applied showing that organ systems connectivity is impaired in patients with decompensated cirrhosis and can predict mortality in cirrhosis independent of current prognostic models while also providing valuable insights into the associated pathological pathways. Moreover, network mapping also predicts response to intravenous albumin in patients hospitalized with decompensated cirrhosis. Thus, this review highlights the importance of evaluating decompensated cirrhosis through the network physiologic prism. It emphasizes the limitations of current prognostic models and the values of network physiologic techniques in cirrhosis.
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Affiliation(s)
- Tope Oyelade
- Institute for Liver and Digestive Health, Division of MedicineUCLLondonUK
- Network Physiology Laboratory, Division of MedicineUCLLondonUK
| | - Kevin P. Moore
- Institute for Liver and Digestive Health, Division of MedicineUCLLondonUK
| | - Ali R. Mani
- Institute for Liver and Digestive Health, Division of MedicineUCLLondonUK
- Network Physiology Laboratory, Division of MedicineUCLLondonUK
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3
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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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Behera SK, Behera P, Behera JR, Behera G. Study of Cardiac Dysfunction in Portal Hypertension: A Single-Center Experience From Eastern India. Cureus 2023; 15:e51259. [PMID: 38283536 PMCID: PMC10822045 DOI: 10.7759/cureus.51259] [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] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Cardiac functional abnormalities are common in patients with cirrhosis of the liver. Nonetheless, the effect of portal hypertension and liver disorder on cardiac abnormalities is yet to be investigated. The current study evaluated the contribution of cirrhotic and non-cirrhotic portal hypertension as the potential cause of cardiac abnormalities. METHODS The present study was a cross-sectional observational study. After excluding known heart diseases, 128 patients with portal hypertension from different causes were enrolled in the study. Cardiac functional activity was assessed by electrocardiogram (ECG) and transthoracic echocardiography (TTE). Results: This study included a total of 128 patients, out of which 24 had extrahepatic portal vein obstruction (EHPVO), four patients had Budd-Chiari syndrome and 100 had liver cirrhosis. Normal ventricular function was observed in patients with EHPVO and Budd-Chiari syndrome. Sixty-eight percent of cases had liver cirrhosis diastolic abnormalities. The mean QTc interval in patients with cirrhotic cardiomyopathy (CCM) was 0.49 ± 0.05 sec which was significantly increased when compared to patients without CCM with 0.432 ± 0.07 at p=0.0016. The Child Turcotte Pugh (CTP) score and MELD (Model for End-Stage Liver Disease) score in patients with CCM were significantly higher as compared to patients without CCM. All alcoholic cirrhotic and non-alcoholic cirrhotic patients had equal prevalence of diastolic dysfunction (p-value >0.05). CONCLUSION Patients with Child class C or a high MELD score are associated with a higher prevalence rate of CCM while normal cardiac function was observed among patients having portal hypertension due to extrahepatic causes. We recommend cardiac evaluation by echocardiography in all cirrhotic patients. Institution of specific medical therapy and early referral for liver transplantation should be considered to improve survival in patients with decompensated cirrhosis.
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Affiliation(s)
- Sambit Kumar Behera
- Gastroenterology, Srirama Chandra Bhanja (SCB) Medical College, Cuttack, IND
| | - Prajyoti Behera
- Physiology, Institute of Medical Sciences (IMS) & SUM Hospital, Bhubaneswar, IND
| | | | - Gayatri Behera
- Pathology, Institute of Medical Sciences (IMS) & SUM Hospital, Bhubaneswar, IND
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Liu H, Nguyen HH, Hwang SY, Lee SS. Oxidative Mechanisms and Cardiovascular Abnormalities of Cirrhosis and Portal Hypertension. Int J Mol Sci 2023; 24:16805. [PMID: 38069125 PMCID: PMC10706054 DOI: 10.3390/ijms242316805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
In patients with portal hypertension, there are many complications including cardiovascular abnormalities, hepatorenal syndrome, ascites, variceal bleeding, and hepatic encephalopathy. The underlying mechanisms are not yet completely clarified. It is well known that portal hypertension causes mesenteric congestion which produces reactive oxygen species (ROS). ROS has been associated with intestinal mucosal injury, increased intestinal permeability, enhanced gut bacterial overgrowth, and translocation; all these changes result in increased endotoxin and inflammation. Portal hypertension also results in the development of collateral circulation and reduces liver mass resulting in an overall increase in endotoxin/bacteria bypassing detoxication and immune clearance in the liver. Endotoxemia can in turn aggravate oxidative stress and inflammation, leading to a cycle of gut barrier dysfunction → endotoxemia → organ injury. The phenotype of cardiovascular abnormalities includes hyperdynamic circulation and cirrhotic cardiomyopathy. Oxidative stress is often accompanied by inflammation; thus, blocking oxidative stress can minimize the systemic inflammatory response and alleviate the severity of cardiovascular diseases. The present review aims to elucidate the role of oxidative stress in cirrhosis-associated cardiovascular abnormalities and discusses possible therapeutic effects of antioxidants on cardiovascular complications of cirrhosis including hyperdynamic circulation, cirrhotic cardiomyopathy, and hepatorenal syndrome.
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Affiliation(s)
| | | | | | - Samuel S. Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada (H.H.N.); (S.Y.H.)
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Liu H, Hwang SY, Lee SS. Role of Galectin in Cardiovascular Conditions including Cirrhotic Cardiomyopathy. Pharmaceuticals (Basel) 2023; 16:978. [PMID: 37513890 PMCID: PMC10386075 DOI: 10.3390/ph16070978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Abnormal cardiac function in the setting of cirrhosis and in the absence of a primary cardiac disease is known as cirrhotic cardiomyopathy. The pathogenesis of cirrhotic cardiomyopathy is multifactorial but broadly is comprised of two pathways. The first is due to cirrhosis and synthetic liver failure with abnormal structure and function of many substances, including proteins, lipids, hormones, and carbohydrates such as lectins. The second is due to portal hypertension which invariably accompanies cirrhosis. Portal hypertension leads to a leaky, congested gut with resultant endotoxemia and systemic inflammation. This inflammatory phenotype comprises oxidative stress, cellular apoptosis, and inflammatory cell infiltration. Galectins exert all these pro-inflammatory mechanisms across many different tissues and organs, including the heart. Effective therapies for improving cardiac function in patients with cirrhosis are not available. Conventional strategies for other noncirrhotic heart diseases, including vasodilators, are not feasible because of the significant baseline vasodilation in cirrhotic patients. Therefore, exploring new treatment modalities for cirrhotic cardiomyopathy is of great importance. Galectin-3 inhibitors such as modified citrus pectin, N-acetyllactosamine, TD139 and GB0139 exert anti-apoptotic, anti-oxidative and anti-inflammatory effects and thus have potential therapeutic interest. This review briefly summarizes the physiological and pathophysiological role of galectin and specifically examines its role in cardiac disease processes. We present a more detailed discussion of galectin in cardiovascular complications of cirrhosis, particularly cirrhotic cardiomyopathy. Finally, therapeutic studies of galectin-3 inhibitors in cirrhotic cardiomyopathy are reviewed.
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Affiliation(s)
- Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
| | - Sang-Youn Hwang
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
- Department of Internal Medicine, Dongnam Institute of Radiological & Medical Sciences, Busan 46033, Republic of Korea
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
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Hwang SY, Liu H, Lee SS. Dysregulated Calcium Handling in Cirrhotic Cardiomyopathy. Biomedicines 2023; 11:1895. [PMID: 37509534 PMCID: PMC10377313 DOI: 10.3390/biomedicines11071895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Cirrhotic cardiomyopathy is a syndrome of blunted cardiac systolic and diastolic function in patients with cirrhosis. However, the mechanisms remain incompletely known. Since contractility and relaxation depend on cardiomyocyte calcium transients, any factors that impact cardiac contractile and relaxation functions act eventually through calcium transients. In addition, calcium transients play an important role in cardiac arrhythmias. The present review summarizes the calcium handling system and its role in cardiac function in cirrhotic cardiomyopathy and its mechanisms. The calcium handling system includes calcium channels on the sarcolemmal plasma membrane of cardiomyocytes, the intracellular calcium-regulatory apparatus, and pertinent proteins in the cytosol. L-type calcium channels, the main calcium channel in the plasma membrane of cardiomyocytes, are decreased in the cirrhotic heart, and the calcium current is decreased during the action potential both at baseline and under stimulation of beta-adrenergic receptors, which reduces the signal to calcium-induced calcium release. The study of sarcomere length fluctuations and calcium transients demonstrated that calcium leakage exists in cirrhotic cardiomyocytes, which decreases the amount of calcium storage in the sarcoplasmic reticulum (SR). The decreased storage of calcium in the SR underlies the reduced calcium released from the SR, which results in decreased cardiac contractility. Based on studies of heart failure with non-cirrhotic cardiomyopathy, it is believed that the calcium leakage is due to the destabilization of interdomain interactions (dispersion) of ryanodine receptors (RyRs). A similar dispersion of RyRs may also play an important role in reduced contractility. Multiple defects in calcium handling thus contribute to the pathogenesis of cirrhotic cardiomyopathy.
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Affiliation(s)
- Sang Youn Hwang
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
- Department of Internal Medicine, Dongnam Institute of Radiological & Medical Sciences, Busan 46033, Republic of Korea
| | - Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
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Sepehrinezhad A, Stolze Larsen F, Ashayeri Ahmadabad R, Shahbazi A, Sahab Negah S. The Glymphatic System May Play a Vital Role in the Pathogenesis of Hepatic Encephalopathy: A Narrative Review. Cells 2023; 12:cells12070979. [PMID: 37048052 PMCID: PMC10093707 DOI: 10.3390/cells12070979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/20/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neurological complication of liver disease resulting in cognitive, psychiatric, and motor symptoms. Although hyperammonemia is a key factor in the pathogenesis of HE, several other factors have recently been discovered. Among these, the impairment of a highly organized perivascular network known as the glymphatic pathway seems to be involved in the progression of some neurological complications due to the accumulation of misfolded proteins and waste substances in the brain interstitial fluids (ISF). The glymphatic system plays an important role in the clearance of brain metabolic derivatives and prevents aggregation of neurotoxic agents in the brain ISF. Impairment of it will result in aggravated accumulation of neurotoxic agents in the brain ISF. This could also be the case in patients with liver failure complicated by HE. Indeed, accumulation of some metabolic by-products and agents such as ammonia, glutamine, glutamate, and aromatic amino acids has been reported in the human brain ISF using microdialysis technique is attributed to worsening of HE and correlates with brain edema. Furthermore, it has been reported that the glymphatic system is impaired in the olfactory bulb, prefrontal cortex, and hippocampus in an experimental model of HE. In this review, we discuss different factors that may affect the function of the glymphatic pathways and how these changes may be involved in HE.
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Affiliation(s)
- Ali Sepehrinezhad
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran 1449614535, Iran
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad 9919191778, Iran
| | - Fin Stolze Larsen
- Department of Gastroenterology and Hepatology, Rigshospitalet, Copenhagen University Hospital, 999017 Copenhagen, Denmark
| | | | - Ali Shahbazi
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran 1449614535, Iran
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran 1449614535, Iran
| | - Sajad Sahab Negah
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad 9919191778, Iran
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran 1449614535, Iran
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The correlation in echocardiogram to right heart catheterization in identifying pulmonary hypertension as a barrier to liver transplantation. Am J Med Sci 2023; 365:496-501. [PMID: 36933862 DOI: 10.1016/j.amjms.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/31/2022] [Accepted: 03/09/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) and portopulmonary hypertension (POPH) can be limitations towards listing for liver transplantation (LT). Our study evaluates the correlation of right ventricular systolic pressure (RVSP) and mean pulmonary artery pressure (mPAP) on transthoracic echocardiogram (TTE) compared to mPAP on right heart catheterization (RHC). METHODS We performed a retrospective review of 723 patients who underwent LT evaluation at our institution between 2012 and 2020. Our cohort consisted of patients with RVSP and mPAP measured on TTE. A Wald t-test and area under the curve analysis were used for statistical analyses. RESULTS Patients with higher mPAP values on TTE (N=33) did not correlate with mPAP ≥ 35 mmHg on RHC, while patients with higher RVSP values (N=147) on TTE were associated with mPAP ≥ 35 mmHg on RHC. The cutoff value of RVSP ≥ 48 mmHg on TTE was associated with mPAP ≥ 35 mmHg on RHC. CONCLUSIONS Our data suggest that RVSP compared to mPAP on TTE is a better indicator for mPAP ≥ 35 mmHg on RHC. RVSP can be used as a marker on echocardiography for identifying patients with a higher likelihood of PH being a barrier to LT listing.
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Kalluru R, Gadde S, Chikatimalla R, Dasaradhan T, Koneti J, Cherukuri SP. Cirrhotic Cardiomyopathy: The Interplay Between Liver and Heart. Cureus 2022; 14:e27969. [PMID: 36120195 PMCID: PMC9467492 DOI: 10.7759/cureus.27969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2022] [Indexed: 11/05/2022] Open
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Tadelle A. QT Interval Prolongation in Cirrhotic Cardiomyopathy. RESEARCH REPORTS IN CLINICAL CARDIOLOGY 2022. [DOI: 10.2147/rrcc.s371615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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12
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Chen T, Huang Z, Chen W, Ding R, Li N, Cui H, Wu F, Liang C, Cong X. Potential cardioprotective influence of bupropion against CCl4-triggered cirrhotic cardiomyopathy. ARAB J CHEM 2022. [DOI: 10.1016/j.arabjc.2021.103599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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13
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Yoon KT, Liu H, Zhang J, Han S, Lee SS. Galectin-3 inhibits cardiac contractility via a TNFα-dependent mechanism in cirrhotic rats. Clin Mol Hepatol 2022; 28:232-241. [PMID: 34986297 PMCID: PMC9013610 DOI: 10.3350/cmh.2021.0141] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 01/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background/Aims Galectin-3 plays a key pathogenic role in cardiac hypertrophy and heart failure. The present study aimed to investigate the effects of galectin-3 on cardiomyopathy – related factors and cardiac contractility in a rat model of cirrhotic cardiomyopathy. Methods Rats were divided into two sets, one for a functional study, the other for cardiac contractile-related protein evaluation. There were four groups in each set: sham operated and sham plus N-acetyllactosamine (N-Lac, a galectin-3 inhibitor; 5 mg/kg); bile duct ligated (BDL) and BDL plus N-Lac. Four weeks after surgery, ventricular level of galectin-3, collagen I and III ratio, tumor necrosis factor alpha (TNFα), and brain natriuretic peptide (BNP) were measured either by Western blots or immunohistochemistry or enzyme-linked immunosorbent assay. Blood pressure was measured by polygraph recorder. Cardiomyocyte contractility was measured by inverted microscopy. Results Galectin-3 and collagen I/III ratio were significantly increased in cirrhotic hearts. TNFα and BNP were significantly increased in BDL serum and heart compared with sham controls. Galectin-3 inhibitor significantly decreased galectin-3, TNFα, and BNP in cirrhotic hearts but not in sham controls. N-Lac also significantly improved the blood pressure, and systolic and diastolic cardiomyocyte contractility in cirrhotic rats but had no effect on sham controls. Conclusion Increased galectin-3 in the cirrhotic heart significantly inhibited contractility via TNFα. Inhibition of galectin-3 decreased the cardiac content of TNFα and BNP and reversed the decreased blood pressure and depressed contractility in the cirrhotic heart. Galectin-3 appears to play a pathogenic role in cirrhotic cardiomyopathy.
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Affiliation(s)
- Ki Tae Yoon
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada.,During these studies, Dr. Yoon was the recipient of a sabbatical leave from Pusan National University Faculty of Medicine, Yangsan Hospital. His current address is: Division of Gastroenterology, Pusan National University, Yangsan Hospital, Yangsan, South Korea
| | - Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Jing Zhang
- Dept of Hepatology and Infectious Disease, Youan Hospital, Capital Medical University, Beijing, China
| | - Sojung Han
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada.,Current address: Division of Gastroenterology, Dept of Internal Medicine, Uijeongbu Eulji Medical Center, Uijeongbu-si, South Korea
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada
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Liu H, Nguyen HH, Yoon KT, Lee SS. Pathogenic Mechanisms Underlying Cirrhotic Cardiomyopathy. FRONTIERS IN NETWORK PHYSIOLOGY 2022; 2:849253. [PMID: 36926084 PMCID: PMC10013066 DOI: 10.3389/fnetp.2022.849253] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 12/14/2022]
Abstract
Cardiac dysfunction associated with cirrhosis in the absence of preexisting heart disease is a condition known as cirrhotic cardiomyopathy (CCM). Cardiac abnormalities consist of enlargement of cardiac chambers, attenuated systolic and diastolic contractile responses to stress stimuli, and repolarization changes. CCM may contribute to cardiovascular morbidity and mortality after liver transplantation and other major surgeries, and also to the pathogenesis of hepatorenal syndrome. The underlying mechanisms of CCM are poorly understood and as such medical therapy is an area of unmet medical need. The present review focuses on the pathogenic mechanisms responsible for development of CCM. The two major concurrent mechanistic pathways are the inflammatory phenotype due to portal hypertension, and protein/lipid synthetic/metabolic defects due to cirrhosis and liver insufficiency. The inflammatory phenotype arises from intestinal congestion due to portal hypertension, resulting in bacteria/endotoxin translocation into the systemic circulation. The cytokine storm associated with inflammation, particularly TNFα acting via NFκB depresses cardiac function. They also stimulate two evanescent gases, nitric oxide and carbon monoxide which produce cardiodepression by cGMP. Inflammation also stimulates the endocannabinoid CB-1 pathway. These systems inhibit the stimulatory beta-adrenergic contractile pathway. The liver insufficiency of cirrhosis is associated with defective synthesis or metabolism of several substances including proteins and lipids/lipoproteins. The protein defects including titin and collagen contribute to diastolic dysfunction. Other protein abnormalities such as a switch of myosin heavy chain isoforms result in systolic dysfunction. Lipid biochemical changes at the cardiac sarcolemmal plasma membrane result in increased cholesterol:phospholipid ratio and decreased membrane fluidity. Final common pathway changes involve abnormal cardiomyocyte intracellular ion kinetics, particularly calcium. In conclusion, cirrhotic cardiomyopathy is caused by two pathways of cellular and molecular dysfunction/damage due to hepatic insufficiency and portal hypertension.
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Affiliation(s)
- Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Henry H Nguyen
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Ki Tae Yoon
- Liver Center, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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15
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Kaur H, Premkumar M. Diagnosis and Management of Cirrhotic Cardiomyopathy. J Clin Exp Hepatol 2022; 12:186-199. [PMID: 35068798 PMCID: PMC8766707 DOI: 10.1016/j.jceh.2021.08.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cirrhotic cardiomyopathy refers to the structural and functional changes in the heart leading to either impaired systolic, diastolic, electrocardiographic, and neurohormonal changes associated with cirrhosis and portal hypertension. Cirrhotic cardiomyopathy is present in 50% of patients with cirrhosis and is clinically seen as impaired contractility, diastolic dysfunction, hyperdynamic circulation, and electromechanical desynchrony such as QT prolongation. In this review, we will discuss the cardiac physiology principles underlying cirrhotic cardiomyopathy, imaging techniques such as cardiac magnetic resonance imaging and scintigraphy, cardiac biomarkers, and newer echocardiographic techniques such as tissue Doppler imaging and speckle tracking, and emerging treatments to improve outcomes. METHODS We reviewed available literature from MEDLINE for randomized controlled trials, cohort studies, cross-sectional studies, and real-world outcomes using the search terms "cirrhotic cardiomyopathy," "left ventricular diastolic dysfunction," "heart failure in cirrhosis," "liver transplantation," and "coronary artery disease". RESULTS Cirrhotic cardiomyopathy is associated with increased risk of complications such as hepatorenal syndrome, refractory ascites, impaired response to stressors including sepsis, bleeding or transplantation, poor health-related quality of life and increased morbidity and mortality. The evaluation of cirrhotic cardiomyopathy should also guide the feasibility of procedures such as transjugular intrahepatic portosystemic shunt, dose titration protocol of betablockers, and liver transplantation. The use of targeted heart rate reduction is of interest to improve cardiac filling and improve the cardiac output using repurposed heart failure drugs such as ivabradine. Liver transplantation may also reverse the cirrhotic cardiomyopathy; however, careful cardiac evaluation is necessary to rule out coronary artery disease and improve cardiac outcomes in the perioperative period. CONCLUSION More data are needed on the new diagnostic criteria, molecular and biochemical changes, and repurposed drugs in cirrhotic cardiomyopathy. The use of advanced imaging techniques should be incorporated in clinical practice.
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Key Words
- 2-AG, 2-arachidonylglycerol
- 2D, two-dimensional
- AEA, Anandamide
- ANP, Atrial Natriuretic Peptide
- ASE, the American Society of Echocardiography
- AUC, area under the curve
- BA, bile acid
- BNP, Brain natriuretic peptide
- CAD, coronary artery disease
- CB-1, cannabinoid −1
- CCM, Cirrhotic Cardiomyopathy
- CMR, cardiovascular magnetic resonance imaging
- CO, cardiac output
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- CVP, central venous pressure
- DT, deceleration Time
- ECG, electrocardiogram
- ECV, extracellular volume
- EF, Ejection fraction
- EMD, electromechanical desynchrony
- ESLD, end-stage liver disease
- FXR, Farnesoid X receptor
- GI, gastrointestinal
- GLS, Global Longitudinal strain
- HCN, Hyperpolarization-activated cyclic nucleotide–gated
- HE, hepatic encephalopathy
- HF, heart failure
- HO, Heme oxygenase
- HPS, hepatopulmonary syndrome
- HR, heart rate
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- HfmrEF, heart failure with mid-range ejection fraction
- HfrEF, heart failure with reduced ejection fraction
- IVC, Inferior Vena Cava
- IVCD, IVC Diameter
- IVS, intravascular volume status
- L-NAME, NG-nitro-L-arginine methyl ester
- LA, left atrium
- LAVI, LA volume index
- LGE, late gadolinium enhancement
- LT, liver transplant
- LV, left ventricle
- LVDD, left ventricular diastolic dysfunction
- LVEDP, left ventricular end-diastolic pressure
- LVEDV, LV end diastolic volume
- LVEF, left ventricular ejection fraction
- LVESV, LV end systolic volume
- LVOT, left ventricular outflow tract
- MAP, mean arterial pressure
- MELD, Model for End-Stage Liver Disease
- MR, mitral regurgitation
- MRI, Magnetic resonance imaging
- MV, mitral valve
- NAFLD, Nonalcoholic fatty liver disease
- NO, nitric oxide
- NOS, Nitric oxide synthases
- NTProBNP, N-terminal proBNP
- PAP, pulmonary artery pressure
- PCWP, pulmonary capillary wedged pressure
- PHT, portal hypertension
- PWD, Pulsed-wave Doppler
- RV, right ventricle
- RVOT, right ventricular outflow tract
- SA, sinoatrial
- SD, standard deviation
- SV, stroke volume
- SVR, Systemic vascular resistance
- TDI, tissue Doppler imaging
- TIPS, transjugular intrahepatic portosystemic shunt
- TR, Tricuspid valve
- TRPV1, transient receptor potential cation channel subfamily V member 1
- TTE, transthoracic echocardiography
- USG, ultrasonography
- VTI, velocity time integral
- beta blocker
- cirrhotic cardiomyopathy
- hemodynamics in cirrhosis
- left ventricular diastolic dysfunction
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Affiliation(s)
| | - Madhumita Premkumar
- Address for correspondence: Dr. Madhumita Premkumar, M.D., D.M., Department of Hepatology, Postgraduate Institute of Medical Education and Research, 60012, Chandigarh, India. Tel.: ++91-9540951061 (mobile)
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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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Desai MS. Mechanistic insights into the pathophysiology of cirrhotic cardiomyopathy. Anal Biochem 2021; 636:114388. [PMID: 34587512 DOI: 10.1016/j.ab.2021.114388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/22/2021] [Accepted: 09/15/2021] [Indexed: 02/08/2023]
Abstract
Myocardial dysfunction in end stage cirrhotic liver disease, termed cirrhotic cardiomyopathy, is a long known, but little understood comorbidity seen in ∼50% of adults and children who present for liver transplantation. Structural, functional, hemodynamic and electrocardiographic aberrations that occur in the heart as a direct consequence of a damaged liver, is associated with multi-organ failure and increased mortality and morbidity in patients undergoing surgical procedures such as porto-systemic shunt placement and liver transplantation. Despite its clinical significance and rapid advances in science and pharmacotherapy, there is yet no specific treatment for this disease. This may be due to a lack of understanding of the pathogenesis and mechanisms behind how a cirrhotic liver causes cardiac pathology. This review will focus specifically on insights into the molecular mechanisms that drive this liver-heart interaction. Deeper understanding of the etio-pathogenesis of cirrhotic cardiomyopathy will allow us to design and test treatments that can be targeted to prevent and/or reverse this co-morbid consequence of liver failure and improve health care delivery and outcomes in patients with cirrhosis.
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Affiliation(s)
- Moreshwar S Desai
- Department of Pediatrics, Section of Pediatric Critical Care Medicine and Liver ICU. Baylor College of Medicine, Houston, TX, 77030, USA.
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18
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de Souza SLB, Mota GAF, Gregolin CS, do Nascimento M, Luvizotto RAM, Bazan SGZ, Sugizaki MM, Barbisan LF, Cicogna AC, do Nascimento AF. Exercise Training Attenuates Cirrhotic Cardiomyopathy. J Cardiovasc Transl Res 2021; 14:674-684. [PMID: 32246321 DOI: 10.1007/s12265-020-09997-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/25/2020] [Indexed: 12/22/2022]
Abstract
Cirrhotic cardiomyopathy is a condition where liver cirrhosis is associated with cardiac dysfunction. Triggers and blockers of cirrhotic cardiomyopathy are poorly understood, which might compromise the prognosis of chronic liver disease patients. We tested whether exercise training would reduce liver damage induced by thioacetamide and prevent liver cirrhosis-associated cardiomyopathy. Wistar rats were divided into three groups: control, thioacetamide (TAA), or TAA plus exercise. Thioacetamide increased liver weight and serum alanine aminotransferase and aspartate aminotransferase levels. Also, TAA treatment was involved with hepatic nodule formation, fibrotic septa, inflammatory infiltration, and hepatocyte necrosis. The exercise group presented with a reduction in liver injury status. We found that liver injury was associated with disordered cardiac hypertrophy as well as diastolic and systolic dysfunction. Exercise training attenuated cirrhosis-associated cardiac remodeling and diastolic dysfunction and prevented systolic impairment. These results provided insights that exercise training can mitigate cirrhotic cardiomyopathy phenotype. Graphical Abstract Exercise training attenuated liver injury as well as cirrhosis-associated cardiac remodeling and diastolic dysfunction and prevented systolic impairment.
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Affiliation(s)
- Sérgio Luiz Borges de Souza
- Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Gustavo Augusto Ferreira Mota
- Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Cristina Schmitt Gregolin
- Institute of Health Sciences, Federal University of Mato Grosso (UFMT), Avenida Alexandre Ferronato, n°1200, Setor Industrial, Sinop, Mato Grosso, 78.556-267, Brazil
| | - Milena do Nascimento
- Institute of Health Sciences, Federal University of Mato Grosso (UFMT), Avenida Alexandre Ferronato, n°1200, Setor Industrial, Sinop, Mato Grosso, 78.556-267, Brazil
| | - Renata Azevedo Melo Luvizotto
- Institute of Health Sciences, Federal University of Mato Grosso (UFMT), Avenida Alexandre Ferronato, n°1200, Setor Industrial, Sinop, Mato Grosso, 78.556-267, Brazil
| | - Silmeia Garcia Zanati Bazan
- Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Mário Mateus Sugizaki
- Institute of Health Sciences, Federal University of Mato Grosso (UFMT), Avenida Alexandre Ferronato, n°1200, Setor Industrial, Sinop, Mato Grosso, 78.556-267, Brazil
| | - Luis Fernando Barbisan
- Department of Morphology, Institute of Biosciences, Sao Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Antonio Carlos Cicogna
- Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - André Ferreira do Nascimento
- Institute of Health Sciences, Federal University of Mato Grosso (UFMT), Avenida Alexandre Ferronato, n°1200, Setor Industrial, Sinop, Mato Grosso, 78.556-267, Brazil.
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Abstract
Cirrhotic cardiomyopathy (CCM), cardiac dysfunction in end-stage liver disease in the absence of prior heart disease, is an important clinical entity that contributes significantly to morbidity and mortality. The original definition for CCM, established in 2005 at the World Congress of Gastroenterology (WCG), was based upon known echocardiographic parameters to identify subclinical cardiac dysfunction in the absence of overt structural abnormalities. Subsequent advances in cardiovascular imaging and in particular myocardial deformation imaging have rendered the WCG criteria outdated. A number of investigations have explored other factors relevant to CCM, including serum markers, electrocardiography, and magnetic resonance imaging. CCM characteristics include a hyperdynamic circulatory state, impaired contractility, altered diastolic relaxation, and electrophysiological abnormalities, particularly QT interval prolongation. It is now known that cardiac dysfunction worsens with the progression of cirrhosis. Treatment for CCM has traditionally been limited to supportive efforts, but new pharmacological studies appear promising. Left ventricular diastolic dysfunction in CCM can be improved by targeted heart rate reduction. Ivabradine combined with carvedilol improves left ventricular diastolic dysfunction through targeted heart rate reduction, and this regimen can improve survival in patients with cirrhosis. Orthotopic liver transplantation also appears to improve CCM. Here, we canvass diagnostic challenges associated with CCM, introduce cardiac physiology principles and the application of echocardiographic techniques, and discuss the evidence behind therapeutic interventions in CCM.
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20
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Chelakkat M, Jacob M, Sebastian S, Paul G, NM A, Joy B, Afsal M. Echocardiographic abnormalities in patients with chronic liver disease: Observations from Thrissur, Kerala, India. MGM JOURNAL OF MEDICAL SCIENCES 2021. [DOI: 10.4103/mgmj.mgmj_84_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Dragičević M, Košuta I, Kruezi E, Lovrenčić MV, Mrzljak A. Association of Asymmetric Dimethylarginine and Nitric Oxide with Cardiovascular Risk in Patients with End-Stage Liver Disease. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:medicina56110622. [PMID: 33218157 PMCID: PMC7698953 DOI: 10.3390/medicina56110622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Endothelial dysfunction has been proposed to be an underlying mechanism of the pronounced cardiovascular morbidity in end-stage liver disease (ESLD), but clinical evidence is still limited. In this study, we investigated the association of circulating levels of asymmetric dimethylarginine (ADMA) and nitric oxide (NO) with estimated cardiovascular risk in patients with ESLD awaiting liver transplantation. MATERIALS AND METHODS ADMA and NO levels were measured in the sera of 160 adult ESLD patients. The severity of hepatic dysfunction was assessed by the model for end-stage liver disease (MELD) score. The cardiovascular risk was estimated with the European Society of Cardiology Systematic Coronary Risk Estimation (SCORE) index, which was used to dichotomize patients in the subgroups depicting higher and lower cardiovascular risk. RESULTS Severe hepatic dysfunction (MELD ≥ 18) was present in 38% of the patients, and a higher cardiovascular risk was present in almost half of the patients (N = 74). ADMA and NO both significantly increased with the progression of liver disease and were independently associated with higher cardiovascular risk. Fasting glucose also independently predicted a higher cardiovascular risk, while HDL cholesterol and the absence of concomitant hepatocellular carcinoma were protective factors. CONCLUSIONS These results suggest a remarkable contribution of the deranged arginine/NO pathway to cardiovascular risk in patients with end-stage liver disease.
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Affiliation(s)
- Maro Dragičević
- Department of Cardiology, Merkur University Hospital, 10000 Zagreb, Croatia;
| | - Iva Košuta
- Department of Internal Medicine, University Hospital Centre, 10000 Zagreb, Croatia;
| | - Egon Kruezi
- Department of Gynaecology and Obstetrics, Sisters of Charity University Hospital Centre, 10000 Zagreb, Croatia;
| | - Marijana Vučić Lovrenčić
- Department of Clinical Chemistry and Laboratory Medicie, Merkur University Hospital, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-1-2353-861
| | - Anna Mrzljak
- Department of Gastroenterology, Merkur University Hospital, 10000 Zagreb, Croatia;
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
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22
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Interplay of cardiovascular mediators, oxidative stress and inflammation in liver disease and its complications. Nat Rev Cardiol 2020; 18:117-135. [PMID: 32999450 DOI: 10.1038/s41569-020-0433-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The liver is a crucial metabolic organ that has a key role in maintaining immune and endocrine homeostasis. Accumulating evidence suggests that chronic liver disease might promote the development of various cardiac disorders (such as arrhythmias and cardiomyopathy) and circulatory complications (including systemic, splanchnic and pulmonary complications), which can eventually culminate in clinical conditions ranging from portal and pulmonary hypertension to pulmonary, cardiac and renal failure, ascites and encephalopathy. Liver diseases can affect cardiovascular function during the early stages of disease progression. The development of cardiovascular diseases in patients with chronic liver failure is associated with increased morbidity and mortality, and cardiovascular complications can in turn affect liver function and liver disease progression. Furthermore, numerous infectious, inflammatory, metabolic and genetic diseases, as well as alcohol abuse can also influence both hepatic and cardiovascular outcomes. In this Review, we highlight how chronic liver diseases and associated cardiovascular effects can influence different organ pathologies. Furthermore, we explore the potential roles of inflammation, oxidative stress, vasoactive mediator imbalance, dysregulated endocannabinoid and autonomic nervous systems and endothelial dysfunction in mediating the complex interplay between the liver and the systemic vasculature that results in the development of the extrahepatic complications of chronic liver disease. The roles of ageing, sex, the gut microbiome and organ transplantation in this complex interplay are also discussed.
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Abstract
PURPOSE OF REVIEW Cirrhotic cardiomyopathy is a syndrome of depressed cardiac function in patients with cirrhosis. We aimed to review the historical background, pathophysiology and pathogenesis, diagnostic definitions, clinical relevance, and management of this syndrome. RECENT FINDINGS An inflammatory phenotype underlies the pathogenesis: gut bacterial translocation with endotoxemia stimulates cytokines and cardiodepressant factors, such as nitric oxide and endocannabinoids. Cardiomyocyte plasma membrane biochemical and biophysical changes also play a pathogenic role. These factors lead to impaired beta-adrenergic function. Proposed new echocardiographic criteria for the diagnosis of cirrhotic cardiomyopathy include systolic global longitudinal strain and indices of diastolic dysfunction. Cardiac dysfunction participates in the pathogenesis of hepatorenal syndrome and increased morbidity/mortality of cirrhotic patients to hemorrhage, infection, and surgery, including liver transplantation. There is no specific treatment, although β-adrenergic blockade and supportive management have been proposed, but it needs further study. Cirrhotic cardiomyopathy is a clinically relevant syndrome afflicting patients with established cirrhosis. Optimum management remains unclear, and further study is needed in this area.
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Affiliation(s)
- Ki Tae Yoon
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.,Liver Center, Department of Internal Medicine, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongnam, 50612, South Korea
| | - Hongqun Liu
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Samuel S Lee
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
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Arya S, Deshpande H, Belwal S, Sharma P, Sadana P, Chandrakant, Rahman F, Gupta M, Uniyal B. Association between cardiac dysfunction, arrhythmias and chronic liver diseases: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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El Hadi H, Di Vincenzo A, Vettor R, Rossato M. Relationship between Heart Disease and Liver Disease: A Two-Way Street. Cells 2020; 9:cells9030567. [PMID: 32121065 PMCID: PMC7140474 DOI: 10.3390/cells9030567] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/18/2022] Open
Abstract
In clinical practice, combined heart and liver dysfunctions coexist in the setting of the main heart and liver diseases because of complex cardiohepatic interactions. It is becoming increasingly crucial to identify these interactions between heart and liver in order to ensure an effective management of patients with heart or liver disease to provide an improvement in overall prognosis and therapy. In this review, we aim to summarize the cross-talk between heart and liver in the setting of the main pathologic conditions affecting these organs. Accordingly, we present the clinical manifestation, biochemical profiles, and histological findings of cardiogenic ischemic hepatitis and congestive hepatopathy due to acute and chronic heart failure, respectively. In addition, we discuss the main features of cardiac dysfunction in the setting of liver cirrhosis, nonalcoholic fatty liver disease, and those following liver transplantation.
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Affiliation(s)
- Hamza El Hadi
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
- Department of Medicine, Klinikum Rheine, 48431 Rheine, Germany
| | - Angelo Di Vincenzo
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
| | - Roberto Vettor
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
| | - Marco Rossato
- Internal Medicine 3, Department of Medicine—DIMED, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; (H.E.H.); (A.D.V.); (R.V.)
- Correspondence: ; Tel.: +39-049-8218747; Fax: +39049-8213332
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26
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Carvalho MVH, Kroll PC, Kroll RTM, Carvalho VN. Cirrhotic cardiomyopathy: the liver affects the heart. ACTA ACUST UNITED AC 2019; 52:e7809. [PMID: 30785477 PMCID: PMC6376321 DOI: 10.1590/1414-431x20187809] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
Abstract
Cirrhotic cardiomyopathy historically has been confused as alcoholic cardiomyopathy. The key points for diagnosis of cirrhotic cardiomyopathy have been well explained, however this entity was neglected for a long time. Nowadays the diagnosis of this entity has become important because it is a factor that contributes significantly to morbidity-mortality in cirrhotic patients. Characteristics of cirrhotic cardiomyopathy are a hyperdynamic circulatory state, altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, particularity QT interval prolongation. The pathogenesis includes impaired function of beta-receptors, altered transmembrane currents and overproduction of cardiodepressant factors, such as nitric oxide, cytokines and endogenous cannabinoids. In addition to physical signs of hyperdynamic state and heart failure under stress conditions, the diagnosis can be done with dosage of serum markers, electrocardiography, echocardiography and magnetic resonance. The treatment is mainly supportive, but orthotopic liver transplantation appears to improve this condition although the prognosis of liver transplantation in patients with cirrhotic cardiomyopathy is uncertain.
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Affiliation(s)
- M V H Carvalho
- Departamento de Cirurgia, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - P C Kroll
- Hospital de Transplante E.J. Zerbini, São Paulo, SP, Brasil
| | - R T M Kroll
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - V N Carvalho
- Hospital Municipal Dr. Mario Gatti, Campinas, SP, Brasil
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27
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Abstract
BACKGROUND Increasing evidence reveals a close and reciprocal link between acute-on-chronic liver failure (ACLF) and immunodysfunction. METHODS A literature search in PubMed and abstract databases of relevant congresses was performed. RESULTS Important characteristics of liver cirrhosis like tissue hypoxia, cell death, or bacterial translocation maintain a state of chronic inflammation. Precipitating events of ACLF such as infections or alcoholic hepatitis are capable of strongly augmenting cirrhosis-associated systemic inflammation to grades sufficient to induce ACLF-defining organ failures. Chronic systemic inflammation, however, is causally linked to profound immunosuppression. As a consequence, patients with liver cirrhosis and in particular with ACLF are at high risk for severe infections. Promising strategies to ameliorate immunodysfunction, like albumin substitution, administration of recombinant interleukin-22 or granulocyte colony-stimulating factor, antibiotic prophylaxis, or anticoagulation, are under development and offer the chance to specifically prevent and treat ACLF. CONCLUSION A better understanding of the immunopathology of ACLF will likely translate into the implementation of specific therapeutic modalities to prevent and overcome ACLF.
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Affiliation(s)
- Christian M. Lange
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt/Main, Germany
| | - Richard Moreau
- Centre de Recherche sur l'Inflammation (CRI), Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris-Diderot, Paris, France
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28
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Total bile acid levels are associated with left atrial volume and cardiac output in patients with cirrhosis. Eur J Gastroenterol Hepatol 2018; 30:392-397. [PMID: 29227330 DOI: 10.1097/meg.0000000000001043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Bile acids (BAs) are potent signaling molecules involved in the regulation of several metabolic and functional aspects of cardiovascular homeostasis. BA pool alteration in cirrhosis may contribute toward the development of hemodynamic and cardiac disturbances. We aimed to investigate the association between total BA levels and echocardiographic and biochemical markers of cardiac dysfunction in cirrhotic patients. METHODS Cirrhotic patients were enrolled prospectively in this hypothesis-generating study and evaluated for cardiac and hemodynamic dysfunction through clinical, echocardiographic, and biochemical means. Associations between total serum BA concentrations and markers of systolic or diastolic dysfunction and the presence of cirrhotic cardiomyopathy were tested through univariate and multivariate analyses. RESULTS Fifty-eight patients with cirrhosis were assessed in this monocentric study. 49 (85%) patients had decompensated cirrhosis according to the Child class. The median total BA level was 45 µmol/l. There was no correlation between BA levels and the etiology of cirrhosis (P=0.2), current alcohol use (P=0.8), sex (P=0.1), smoking status (P=0.2), age, or BMI. Systolic and diastolic dysfunction were rare in the cohort. Total BA levels associated with several echocardiographic parameters of the hyperdynamic syndrome in univariate analysis but only with left atrial volume in multivariate analysis (P=0.007). BA concentrations did not differ according to the presence of echocardiographically diagnosed cirrhotic cardiomyopathy in the two models tested. CONCLUSION Total serum BA levels are associated with enlarged left atrial volume and markers of the hyperdynamic circulation in patients with cirrhosis irrespective of the etiology or the severity of liver disease.
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29
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Vasavan T, Ferraro E, Ibrahim E, Dixon P, Gorelik J, Williamson C. Heart and bile acids - Clinical consequences of altered bile acid metabolism. Biochim Biophys Acta Mol Basis Dis 2018; 1864:1345-1355. [PMID: 29317337 DOI: 10.1016/j.bbadis.2017.12.039] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/11/2022]
Abstract
Cardiac dysfunction has an increased prevalence in diseases complicated by liver cirrhosis such as primary biliary cholangitis and primary sclerosing cholangitis. This observation has led to research into the association between abnormalities in bile acid metabolism and cardiac pathology. Approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy. Bile acids are directly implicated in this, causing QT interval prolongation, cardiac hypertrophy, cardiomyocyte apoptosis and abnormal haemodynamics of the heart. Elevated maternal serum bile acids in intrahepatic cholestasis of pregnancy, a disorder which causes an impaired feto-maternal bile acid gradient, have been associated with fatal fetal arrhythmias. The hydrophobicity of individual bile acids in the serum bile acid pool is of relevance, with relatively lipophilic bile acids having a more harmful effect on the heart. Ursodeoxycholic acid can reverse or protect against these detrimental cardiac effects of elevated bile acids.
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Affiliation(s)
- Tharni Vasavan
- Department of Women and Children's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL London, United Kingdom
| | - Elisa Ferraro
- National Heart and Lung Institute, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, W12 0NN London, United Kingdom
| | - Effendi Ibrahim
- National Heart and Lung Institute, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, W12 0NN London, United Kingdom; Faculty of Medicine, MARA University of Technology, 40000 Sungai Buloh, Malaysia
| | - Peter Dixon
- Department of Women and Children's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL London, United Kingdom
| | - Julia Gorelik
- National Heart and Lung Institute, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, W12 0NN London, United Kingdom
| | - Catherine Williamson
- Department of Women and Children's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL London, United Kingdom.
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30
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Amirtharaj GJ, Natarajan SK, Pulimood A, Balasubramanian KA, Venkatraman A, Ramachandran A. Role of Oxygen Free Radicals, Nitric Oxide and Mitochondria in Mediating Cardiac Alterations During Liver Cirrhosis Induced by Thioacetamide. Cardiovasc Toxicol 2017; 17:175-184. [PMID: 27131982 DOI: 10.1007/s12012-016-9371-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Thioacetamide (TAA) administration is widely used for induction of liver cirrhosis in rats, where reactive oxygen radicals (ROS) and nitric oxide (NO) participate in development of liver damage. Cardiac dysfunction is an important complication of liver cirrhosis, but the role of ROS or NO in cardiac abnormalities during liver cirrhosis is not well understood. This was investigated in animals after TAA-induced liver cirrhosis and temporal changes in oxidative stress, NO and mitochondrial function in the heart evaluated. TAA induced elevation in cardiac levels of nitrate before development of frank liver cirrhosis, without gross histological alterations. This was accompanied by an early induction of P38 MAP kinase, which is influenced by ROS and plays an important signaling role for induction of iNOS. Increased nitrotyrosine, protein oxidation and lipid peroxidation in the heart and cardiac mitochondria, suggestive of oxidative stress, also preceded frank liver cirrhosis. However, compromised cardiac mitochondrial function with a decrease in respiratory control ratio and increased mitochondrial swelling was seen later, when cirrhosis was evident. In conclusion, TAA induces elevations in ROS and NO in the heart in parallel to early liver damage. This leads to later development of functional deficits in cardiac mitochondria after development of liver cirrhosis.
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Affiliation(s)
- G Jayakumar Amirtharaj
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Ida Scudder Road, Vellore, 632004, India
| | - Sathish Kumar Natarajan
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Ida Scudder Road, Vellore, 632004, India
| | - Anna Pulimood
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Ida Scudder Road, Vellore, 632004, India
| | - K A Balasubramanian
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Ida Scudder Road, Vellore, 632004, India
| | - Aparna Venkatraman
- Center for Stem Cell Research, Christian Medical College, Ida Scudder Road, Vellore, 632004, India
| | - Anup Ramachandran
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Ida Scudder Road, Vellore, 632004, India.
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Voiosu A, Wiese S, Voiosu T, Bendtsen F, Møller S. Bile acids and cardiovascular function in cirrhosis. Liver Int 2017; 37:1420-1430. [PMID: 28222247 DOI: 10.1111/liv.13394] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/12/2017] [Indexed: 02/13/2023]
Abstract
Cirrhotic cardiomyopathy and the hyperdynamic syndrome are clinically important complications of cirrhosis, but their exact pathogenesis is still partly unknown. Experimental models have proven the cardiotoxic effects of bile acids and recent studies of their varied receptor-mediated functions offer new insight into their involvement in cardiovascular dysfunction in cirrhosis. Bile acid receptors such as farnesoid X-activated receptor and TGR5 are currently under investigation as potential therapeutic targets in a variety of pathological conditions. These receptors have also recently been identified in cardiomyocytes, vascular endothelial cells and smooth muscle cells where they seem to play an important role in cellular metabolism. Chronic cholestasis leading to abnormal levels of circulating bile acids alters the normal signalling pathways and contributes to the development of profound cardiovascular disturbances. This review summarizes the evidence regarding the role of bile acids and their receptors in the generation of cardiovascular dysfunction in cirrhosis.
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Affiliation(s)
- Andrei Voiosu
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.,Gastroenterology and Hepatology Department, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Signe Wiese
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Theodor Voiosu
- Gastroenterology and Hepatology Department, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Flemming Bendtsen
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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32
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Licata A, Novo G, Colomba D, Tuttolomondo A, Galia M, Camma' C. Cardiac involvement in patients with cirrhosis: a focus on clinical features and diagnosis. J Cardiovasc Med (Hagerstown) 2016; 17:26-36. [PMID: 26065511 DOI: 10.2459/jcm.0000000000000288] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cirrhotic heart has been traditionally considered protected from cardiovascular disease, even if a large amount of literature has recently shown that patients affected by chronic liver disease are exposed to cardiovascular events, as well. Since the first recognition of cardiac involvement in cirrhosis, all published studies explain that decompensated cirrhotic patients suffer from haemodynamic changes, currently known as hyperdynamic syndrome, which finally lead to cirrhotic cardiomyopathy. This is defined by the presence of a subclinical systolic dysfunction unmasked under stress conditions, impaired diastolic function and electrophysiological abnormalities, in the absence of any known cardiac disease. In this review, we will discuss the clinical and diagnostic features of this condition, the prevalence of associated comorbidities, echocardiographic, electrocardiographic and cardiac magnetic resonance hallmarks and the possible diagnostic role of serum biomarkers.
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Affiliation(s)
- Anna Licata
- aSezione di Gastroenterologia ed Epatologia bSezione di Medicina Clinico-Sperimentale, Dipartimento di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Italy cDivisione di Cardiologia dSezione di Radiologia, Dipartimento di Biopatologia e Biotecnologie Mediche, DiBiMEF, Università di Palermo, Palermo, Italy
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Saeedi Saravi SS, Ghazi-Khansari M, Ejtemaei Mehr S, Nobakht M, Mousavi SE, Dehpour AR. Contribution of mammalian target of rapamycin in the pathophysiology of cirrhotic cardiomyopathy. World J Gastroenterol 2016; 22:4685-94. [PMID: 27217700 PMCID: PMC4870075 DOI: 10.3748/wjg.v22.i19.4685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 02/27/2016] [Accepted: 03/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the role of mammalian target of rapamycin (mTOR) in the pathogenesis of cirrhotic cardiomyopathy and the potential of rapamycin to improve this pathologic condition.
METHODS: Male albino Wistar rats weighing 100-120 g were treated with tetrachloride carbon (CCl4) for 8 wk to induce cirrhosis. Subsequently, animals were administered rapamycin (2 mg/kg per day). The QTc intervals were calculated in a 5-min electrocardiogram. Then, the left ventricular papillary muscles were isolated to examine inotropic responsiveness to β-adrenergic stimulation using a standard organ bath equipped by Powerlab system. Phosphorylated-mTOR localization in left ventricles was immunohistochemically assessed, and ventricular tumor necrosis factor (TNF)-α was measured. Western blot was used to measure levels of ventricular phosphorylated-mTOR protein.
RESULTS: Cirrhosis was confirmed by hematoxylin and eosin staining of liver tissues, visual observation of lethargy, weight loss, jaundice, brown urine, ascites, liver stiffness, and a significant increase of spleen weight (P < 0.001). A significant prolongation in QTc intervals occurred in cirrhotic rats exposed to CCl4 (P < 0.001), while this prolongation was decreased with rapamycin treatment (P < 0.01). CCl4-induced cirrhosis caused a significant decrease of contractile responsiveness to isoproterenol stimulation and a significant increase in cardiac TNF-α. These findings were correlated with data from western blot and immunohistochemical studies on phosphorylated-mTOR expression in left ventricles. Phosphorylated-mTOR was significantly enhanced in cirrhotic rats, especially in the endothelium, compared to controls. Rapamycin treatment significantly increased contractile force and myocardial localization of phosphorylated-mTOR and decreased cardiac TNF-α concentration compared to cirrhotic rats with no treatment.
CONCLUSION: In this study, we demonstrated a potential role for cardiac mTOR in the pathophysiology of cirrhotic cardiomyopathy. Rapamycin normalized the inotropic effect and altered phosphorylated-mTOR expression and myocardial localization in cirrhotic rats.
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Affiliation(s)
- Seyed Soheil Saeedi Saravi
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Mahmoud Ghazi-Khansari
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Shahram Ejtemaei Mehr
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Maliheh Nobakht
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Seyyedeh Elaheh Mousavi
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
| | - Ahmad Reza Dehpour
- Seyed Soheil Saeedi Saravi, Mahmoud Ghazi-Khansari, Shahram Ejtemaei Mehr, Seyyedeh Elaheh Mousavi, Ahmad Reza Dehpour, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran 13145, Iran
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Milić S, Lulić D, Štimac D, Ružić A, Zaputović L. Cardiac manifestations in alcoholic liver disease. Postgrad Med J 2016; 92:235-9. [PMID: 26850503 DOI: 10.1136/postgradmedj-2015-133755] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 01/04/2016] [Indexed: 12/11/2022]
Abstract
Alcoholic liver disease is the most prevalent cause of progressive liver disease in Europe. Alcoholic cirrhosis occurs in 8%-20% of cases of alcoholic liver disease. It has significant influence on cardiovascular system and haemodynamics through increased heart rate, cardiac output, decreased systemic vascular resistance, arterial pressure and plasma volume expansion. Cirrhotic cardiomyopathy is characterised by systolic and diastolic dysfunction and electrophysiological abnormalities, if no other underlying cardiac disease is present. It is often unmasked only during pharmacological or physiological stress, when compensatory mechanisms of the heart become insufficient to maintain adequate cardiac output. Low-to-moderate intake of alcohol can be cardioprotective. However, heavy drinking is associated with an increased risk of cardiovascular diseases, such as alcoholic cardiomyopathy, arterial hypertension, atrial arrhythmias as well as haemorrhagic and ischaemic stroke. Alcoholic cardiomyopathy is characterised by dilated left ventricle (LV), increased LV mass, normal or reduced LV wall thickness and systolic dysfunction.
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Affiliation(s)
- Sandra Milić
- Department of Gastroenterology, Internal Medicine Clinic, University Hospital Rijeka, Rijeka, Croatia
| | - Davorka Lulić
- Department of Cardiovascular Disease, Internal Medicine Clinic, University Hospital Rijeka, Rijeka, Croatia
| | - Davor Štimac
- Department of Gastroenterology, Internal Medicine Clinic, University Hospital Rijeka, Rijeka, Croatia
| | - Alen Ružić
- Department of Cardiovascular Disease, Internal Medicine Clinic, University Hospital Rijeka, Rijeka, Croatia
| | - Luka Zaputović
- Department of Cardiovascular Disease, Internal Medicine Clinic, University Hospital Rijeka, Rijeka, Croatia
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35
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Abstract
Accumulating evidence shows that acute as well as chronic heart disease can directly contribute to an acute or chronic worsening of liver function and vice versa. Description and definition of cardiohepatic syndrome (CHS) in this review are based on the cardiorenal syndrome (CRS) concept. The eye-catching analogy between CHS and CRS is applied to facilitate an understanding of the pathophysiology and overall burden of disease for each of the proposed CHS subtypes, their natural course, and associated morbidity and mortality.
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36
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Téllez Villajos L, Martínez González J, Moreira Vicente V, Albillos Martínez A. Hipertensión pulmonar y cirrosis hepática. Rev Clin Esp 2015; 215:324-30. [DOI: 10.1016/j.rce.2015.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/14/2015] [Accepted: 02/23/2015] [Indexed: 02/07/2023]
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37
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Téllez Villajos L, Martínez González J, Moreira Vicente V, Albillos Martínez A. Pulmonary hypertension and hepatic cirrhosis. Rev Clin Esp 2015. [DOI: 10.1016/j.rceng.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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38
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Abstract
Cirrhotic cardiomyopathy is a cardiac condition observed in patients with cirrhotic regardless of the etiologies. It is characterized by the impaired systolic response to physical stress, diastolic dysfunction, and electrophysiological abnormalities, especially QT interval prolongation. Its pathophysiology and clinical significance has been a focus of various researchers for the past decades. The impairment of β-adrenergic receptor, the increase in endogenous cannabinoids, the presence of cardiosuppressants such as nitric oxide and inflammatory cytokines are the proposed mechanisms of systolic dysfunction. The activation of cardiac renin-angiotensin system and salt retention play the role in the development of cardiac hypertrophy and impaired diastolic function. QT interval prolongation, which is observed in 40-50 % of cirrhotic patients, occurs as a result of the derangement in membrane fluidity and ion channel defect. The increased recognition of this disease will prevent the complications of overt heart failure after procedures such as transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation. Better understandings of the pathogenesis and pathology of cirrhotic cardiomyopathy is crucial in developing more accurate diagnostic tools and specific treatments of this condition.
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Affiliation(s)
| | - Suthat Liangpunsakul
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Hospital, 550 University Boulevard, UH 4100, Indianapolis, IN 46202-5149, USA; Roudebush Veterans Administration Medical Center, Indiana University, Indianapolis, IN, USA
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39
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Abstract
Cirrhotic cardiomyopathy is a cardiac condition observed in patients with cirrhotic regardless of the etiologies. It is characterized by the impaired systolic response to physical stress, diastolic dysfunction, and electrophysiological abnormalities, especially QT interval prolongation. Its pathophysiology and clinical significance has been a focus of various researchers for the past decades. The impairment of β-adrenergic receptor, the increase in endogenous cannabinoids, the presence of cardiosuppressants such as nitric oxide and inflammatory cytokines are the proposed mechanisms of systolic dysfunction. The activation of cardiac renin-angiotensin system and salt retention play the role in the development of cardiac hypertrophy and impaired diastolic function. QT interval prolongation, which is observed in 40-50 % of cirrhotic patients, occurs as a result of the derangement in membrane fluidity and ion channel defect. The increased recognition of this disease will prevent the complications of overt heart failure after procedures such as transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation. Better understandings of the pathogenesis and pathology of cirrhotic cardiomyopathy is crucial in developing more accurate diagnostic tools and specific treatments of this condition.
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Affiliation(s)
| | - Suthat Liangpunsakul
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Hospital, 550 University Boulevard, UH 4100, Indianapolis, IN 46202-5149, USA; Roudebush Veterans Administration Medical Center, Indiana University, Indianapolis, IN, USA
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40
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Angeli P, Tonon M, Pilutti C, Morando F, Piano S. Sepsis-induced acute kidney injury in patients with cirrhosis. Hepatol Int 2015; 10:115-23. [PMID: 26141259 DOI: 10.1007/s12072-015-9641-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/19/2015] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) is a common and life-threatening complication in patients with cirrhosis. Recently, new criteria for the diagnosis of AKI have been proposed in patients with cirrhosis by the International Club of Ascites. Almost all types of bacterial infections can induce AKI in patients with cirrhosis representing its most common precipitating event. The bacterial infection-induced AKI usually meets the diagnostic criteria of hepatorenal syndrome (HRS). Well in keeping with the "splanchnic arterial vasodilation hypothesis", it has been stated that HRS develops as a consequence of a severe reduction of effective circulating volume related to splanchnic arterial vasodilation and to an inadequate cardiac output. Nevertheless, the role of bacterial infections in precipitating organ failures, including renal failure, is enhanced when their course is characterized by the development of a systemic inflammatory response syndrome (SIRS), thus, when sepsis occurs. Sepsis has been shown to be capable to induce "per se" AKI in animals as well as in patients conditioning also the features of renal damage. This observation suggests that when precipitated by sepsis, the pathogenesis and the clinical course of AKI also in patients with cirrhosis may differentiate to a certain extent from AKI with another or no precipitating factor. The purpose of this review is to describe the features of AKI precipitated by bacterial infections and to highlight whether infection and/or the development of SIRS may influence its clinical course, and, in particular, the response to treatment.
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Affiliation(s)
- Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - Marta Tonon
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Chiara Pilutti
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Filippo Morando
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Piano
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
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41
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Gheddouchi S, Mokhtari-Soulimane N, Merzouk H, Bekhti F, Soulimane F, Guermouche B, Meziane Tani A, Narce M. Low SOD activity is associated with overproduction of peroxynitrite and nitric oxide in patients with acute coronary syndrome. Nitric Oxide 2015; 49:40-6. [PMID: 26047756 DOI: 10.1016/j.niox.2015.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 05/20/2015] [Accepted: 05/26/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The present study was undertaken to evaluate the variation of the oxidative/nitrosative stress status in a population of subjects; with acute coronary syndrome (ACS), and examine its possible implication in plaque rupture which is the main mechanism in the pathophysiology of ACS. PATIENTS AND METHODS We made this study on 50 men with ACS and 50 age and sex matched healthy controls. Nitrosative/oxidative stress markers including; nitric oxide, superoxide anion levels, superoxide dismutase (SOD) activity and peroxynitrite levels were evaluated in blood samples of patients and controls. RESULTS Compared with healthy subjects, coronary patients had significantly higher nitric oxide, peroxynitrite and superoxide anion concentrations in both plasma and erythrocytes associated to significant decrease of SOD activity. Erythrocytes peroxynitrite concentration was negatively correlated with the antioxidant enzyme activity (SOD). CONCLUSION Our results show a significant accumulation of both intracellular and plasma pro-oxidants with a concomitant decrease in the SOD scavenging activity in ACS patients. Both seem to be associated with plaque rupture and ischemia observed in ACS.
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Affiliation(s)
- Sabah Gheddouchi
- Laboratory of Physiology, Physiopathology and Biochemistry of Nutrition(PPABIONUT), Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, Abou-Bekr Belkaïd University, Tlemcen 13000, Algeria
| | - Nassima Mokhtari-Soulimane
- Laboratory of Physiology, Physiopathology and Biochemistry of Nutrition(PPABIONUT), Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, Abou-Bekr Belkaïd University, Tlemcen 13000, Algeria.
| | - Hafida Merzouk
- Laboratory of Physiology, Physiopathology and Biochemistry of Nutrition(PPABIONUT), Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, Abou-Bekr Belkaïd University, Tlemcen 13000, Algeria
| | - Fadia Bekhti
- Laboratory of Physiology, Physiopathology and Biochemistry of Nutrition(PPABIONUT), Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, Abou-Bekr Belkaïd University, Tlemcen 13000, Algeria
| | - Fayçal Soulimane
- Cardiology Department of Tlemcen University Hospital Center, Tlemcen 13000, Algeria
| | - Baya Guermouche
- Laboratory of Physiology, Physiopathology and Biochemistry of Nutrition(PPABIONUT), Department of Biology, Faculty of Natural and Life Sciences, Earth and Universe, Abou-Bekr Belkaïd University, Tlemcen 13000, Algeria
| | | | - Michel Narce
- INSERM UMR 866, "Lipids Nutrition Cancer", Faculty of Life, Earth, and Environment Sciences, University of Burgundy, Dijon 21000, France
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Patel H, Madanieh R, Kosmas CE, Vatti SK, Vittorio TJ. Reversible Cardiomyopathies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:7-14. [PMID: 26052233 PMCID: PMC4441366 DOI: 10.4137/cmc.s19703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/12/2015] [Accepted: 01/17/2015] [Indexed: 01/04/2023]
Abstract
Cardiomyopathies (CMs) have many etiological factors that can result in severe structural and functional dysregulation. Fortunately, there are several potentially reversible CMs that are known to improve when the root etiological factor is addressed. In this article, we discuss several of these reversible CMs, including tachycardia-induced, peripartum, inflammatory, hyperthyroidism, Takotsubo, and chronic illness-induced CMs. Our discussion also includes a review on their respective pathophysiology, as well as possible management solutions.
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Affiliation(s)
- Harsh Patel
- SUNY Downstate School of Medicine, Department of Internal Medicine, Brooklyn, NY, USA
| | - Raef Madanieh
- St. Francis Hospital - The Heart Center , Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | - Constantine E Kosmas
- Mount Sinai School of Medicine, Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, USA
| | - Satya K Vatti
- St. Francis Hospital - The Heart Center , Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | - Timothy J Vittorio
- St. Francis Hospital - The Heart Center , Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
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Abstract
Cirrhotic cardiomyopathy, a cardiac dysfunction presented in patients with cirrhosis, represents a recently recognized clinical entity. It is characterized by altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, in particular prolongation of the QT interval. Several mechanisms seem to be involved in the pathogenesis of cirrhotic cardiomyopathy, including impaired function of beta-receptors, altered transmembrane currents, and overproduction of cardiodepressant factors, like nitric oxide, tumor necrosis factor α, and endogenous cannabinoids. Diastolic dysfunction is the first manifestation of cirrhotic cardiomyopathy and reflects the increased stiffness of the cardiac mass, which leads to delayed left ventricular filling. On the other hand, systolic incompetence is presented later, is usually unmasked during pharmacological or physical stress, and predisposes to the development of hepatorenal syndrome. The prolongation of QT is found in about 50 % of cirrhotic patients, but rarely leads to fatal arrhythmias. Cirrhotics with blunted cardiac function seem to have poorer survival rates compared to those without, and the risk is particularly increased during the insertion of transjugular intrahepatic portosystemic shunt or liver transplantation. Till now, there is no specific treatment for the management of cirrhotic cardiomyopathy. New agents, targeting to its pathogenetical mechanisms, may play some role as future therapeutic options.
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44
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Prin M, Bakker J, Wagener G. Hepatosplanchnic circulation in cirrhosis and sepsis. World J Gastroenterol 2015; 21:2582-2592. [PMID: 25759525 PMCID: PMC4351207 DOI: 10.3748/wjg.v21.i9.2582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 11/15/2014] [Accepted: 01/21/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatosplanchnic circulation receives almost half of cardiac output and is essential to physiologic homeostasis. Liver cirrhosis is estimated to affect up to 1% of populations worldwide, including 1.5% to 3.3% of intensive care unit patients. Cirrhosis leads to hepatosplanchnic circulatory abnormalities and end-organ damage. Sepsis and cirrhosis result in similar circulatory changes and resultant multi-organ dysfunction. This review provides an overview of the hepatosplanchnic circulation in the healthy state and in cirrhosis, examines the signaling pathways that may play a role in the physiology of cirrhosis, discusses the physiology common to cirrhosis and sepsis, and reviews important issues in management.
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45
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Gassanov N, Caglayan E, Semmo N, Massenkeil G, Er F. Cirrhotic cardiomyopathy: A cardiologist’s perspective. World J Gastroenterol 2014; 20:15492-15498. [PMID: 25400434 PMCID: PMC4229515 DOI: 10.3748/wjg.v20.i42.15492] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 04/01/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Cardiac dysfunction is frequently observed in patients with cirrhosis, and has long been linked to the direct toxic effect of alcohol. Cirrhotic cardiomyopathy (CCM) has recently been identified as an entity regardless of the cirrhosis etiology. Increased cardiac output due to hyperdynamic circulation is a pathophysiological hallmark of the disease. The underlying mechanisms involved in pathogenesis of CCM are complex and involve various neurohumoral and cellular pathways, including the impaired β-receptor and calcium signaling, altered cardiomyocyte membrane physiology, elevated sympathetic nervous tone and increased activity of vasodilatory pathways predominantly through the actions of nitric oxide, carbon monoxide and endocannabinoids. The main clinical features of CCM include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities and chronotropic incompetence. Particularly the diastolic dysfunction with impaired ventricular relaxation and ventricular filling is a prominent feature of CCM. The underlying mechanism of diastolic dysfunction in cirrhosis is likely due to the increased myocardial wall stiffness caused by myocardial hypertrophy, fibrosis and subendothelial edema, subsequently resulting in high filling pressures of the left ventricle and atrium. Currently, no specific treatment exists for CCM. The liver transplantation is the only established effective therapy for patients with end-stage liver disease and associated cardiac failure. Liver transplantation has been shown to reverse systolic and diastolic dysfunction and the prolonged QT interval after transplantation. Here, we review the pathophysiological basis and clinical features of cirrhotic cardiomyopathy, and discuss currently available limited therapeutic options.
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46
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Cardiomyocyte apoptosis contributes to pathogenesis of cirrhotic cardiomyopathy in bile duct-ligated mice. Clin Sci (Lond) 2014; 127:519-26. [PMID: 24712830 DOI: 10.1042/cs20130642] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cirrhotic cardiomyopathy is defined as systolic and diastolic dysfunctions, electrophysiological changes and macroscopic structural changes. However, the underlying mechanisms of this syndrome remain unclear. A possible role of myocardial apoptosis in the pathogenesis has not been previously examined. We hypothesized that dysregulation of apoptotic signalling participates in cardiac dysfunction in the cirrhotic heart. Therefore, we evaluated apoptotic pathways in the hearts of mice with chronic BDL (bile duct ligation). A cirrhotic cardiomyopathy model was induced by BDL in mice. Left ventricular geometry and volumes were evaluated by MRI. Intrinsic and extrinsic apoptotic pathways were evaluated by immunohistochemical staining and Western blot analysis. Fas-mediated apoptosis was inhibited by in vivo administration of an anti-FasL (Fas ligand) monoclonal antibody, and subsequently cardiac contractility was measured in isolated cardiomyocytes. BDL-mice showed significantly more PARP [poly(ADP-ribose) polymerase] staining than sham controls (18.2±11.4 compared with 6.7±5.3; P<0.05). Fas protein expression and PARP cleavage were activated, whereas FLIP (Fas-associated death domain-like interleukin 1β-converting enzyme-inhibitory protein) was decreased compared with sham controls. The Bcl-2/Bax ratio was increased in BDL-mice compared with sham controls. Anti-FasL monoclonal antibody injection in BDL-mice improved systolic and diastolic dysfunctions in cardiomyocytes, but had no effect in sham controls. A net pro-apoptotic balance exists in BDL hearts, mainly mediated by activation of the extrinsic pathway, and abrogation of apoptosis improved contractility. These results suggest that apoptosis contributes to depressed cardiac contractility in a murine model of cirrhotic cardiomyopathy.
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47
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Abbasi A, Joharimoqaddam A, Faramarzi N, Khosravi M, Jahanzad I, Dehpour AR. Opioid receptors blockade modulates apoptosis in a rat model of cirrhotic cardiomyopathy. Ann Med Health Sci Res 2014; 4:404-9. [PMID: 24971217 PMCID: PMC4071742 DOI: 10.4103/2141-9248.133468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Cirrhosis is a common consequence of chronic liver inflammation is known to be associated with various manifestation of cardiovascular dysfunction, which has been introduced as a cirrhotic cardiomyopathy. Some possible pathogenic mechanisms has been reported and still more details should be explored. Aim: The present study is the first study to explore the contribution of endogenous opioids in the apoptosis process in a rat model of cirrhotic cardiomyopathy. Materials and Methods: Cirrhosis was induced in rats by bile duct ligation (BDL) and resection. Cardiomyopathy was confirmed using trichrome staining for fibrosis. Naltrexone, an opioid antagonist was administered for 29(1) days. Apoptosis was detected using terminal transferase deoxyuridine triphosphate nick end labeling assay with some modification. Statistical evaluation of data was performed using analysis of variance test. P < 0.05 was considered to be statistically significant. Results: Left ventricular (LV) wall thickness was significantly (P < 0.001) lower in the BDL group than the sham group, either receiving naltrexone or saline. No significant difference was seen in LV wall thickness or LV end diastolic diameter in BDL group receiving either saline or naltrexone. The apoptosis density of cardiac specimens of sham operated and BDL rats were dramatically different from each other. The cardiac specimens of BDL rats contained multiple apoptotic cells. In saline treated samples (BDL-saline vs. sham-saline), apoptosis density was significantly increased in BDL-saline group (P < 0.001). Cardiomyocyte apoptosis was significantly decreased in the BDL-naltrexone group compared to BDL-saline group (P < 0.001). There was no significant change in apoptosis density in sham groups receiving either naltrexone or saline. Conclusion: Apoptosis occurs during cirrhotic cardiomyopathy and endogenous opioid receptors blockade using naltrexone decreases its amount, but cardiac function may not be improved.
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Affiliation(s)
- Ata Abbasi
- Department of Pathology, Tehran University of Medical Science, Tehran, Iran ; Department of Cardiology, AJA University of Medical Science, Tehran, Iran
| | | | - Negar Faramarzi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Science, Tehran, Iran
| | - Mohsen Khosravi
- Department of Pathology, Tehran University of Medical Science, Tehran, Iran
| | - Issa Jahanzad
- Department of Pathology, Tehran University of Medical Science, Tehran, Iran
| | - Ahmad R Dehpour
- Department of Pharmacology, Tehran University of Medical Science, Tehran, Iran
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Patel D, Singh P, Katz W, Hughes C, Chopra K, Němec J. QT interval prolongation in end-stage liver disease cannot be explained by nonhepatic factors. Ann Noninvasive Electrocardiol 2014; 19:574-81. [PMID: 24762117 DOI: 10.1111/anec.12161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION QT interval prolongation in patients with end-stage liver disease (ESLD) is common. However, electrolyte abnormalities, renal insufficiency, treatment with QT-prolonging drugs, and other factors known to prolong QT interval independently of liver disease occur frequently in ESLD. Moreover, elevated heart rate may be present in ESLD and result in spurious QTc prolongation if the Bazett formula is used for rate correction. It thus remains unclear whether QT prolongation in ESLD is directly caused by liver failure, or indirectly by these confounding factors. METHODS Medical records of all patients (n = 437) who received orthotopic liver transplantation (OLTx) at our institution between 2008 and 2011 were reviewed. Data from 51 patients with available pre-OLTx dobutamine stress echo (DSE), post-OLTx ECG and without nonhepatic factors affecting QT interval duration were analyzed. For each patient, QT versus RR regression line was calculated from ECG tracings obtained during DSE. The QT interval on post-OLTx ECG was compared with the pre-OLTx QT predicted by the regression line for the same RR interval. RESULTS QT interval shortened significantly post-OLTx (from 394 ± 47 to 364 ± 45 ms at RR interval 750 ± 144 ms; P < 0.002) when compared using the regression method. Corrected QT intervals calculated by Bazett and Fridericia formulas also shortened. Patients with prolonged QT pre-OLTx had significantly higher INR and lower serum albumin. CONCLUSION ESLD impairs ventricular repolarization even in the absence of other known factors affecting repolarization. QT prolongation in ESLD is associated with impaired synthetic liver function.
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Affiliation(s)
- Divyang Patel
- University of Pittsburgh School of Medicine, Pittsburgh, PA
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Sheen JM, Chen YC, Tain YL, Huang LT. Increased circulatory asymmetric dimethylarginine and multiple organ failure: bile duct ligation in rat as a model. Int J Mol Sci 2014; 15:3989-4006. [PMID: 24603538 PMCID: PMC3975379 DOI: 10.3390/ijms15033989] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 02/04/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023] Open
Abstract
Bile duct ligation (BDL)-treated rats exhibit cholestasis, increased systemic oxidative stress, and liver fibrosis, which ultimately lead to liver cirrhosis. Asymmetric dimethylarginine (ADMA) is a competitive inhibitor of nitric oxide synthase that can decrease the synthesis of nitric oxide. BDL rats have higher plasma and hepatic ADMA levels, which may be due to increased hepatic protein arginine methyltransferase-1 and decreased dimethylarginine dimethylaminohydrolase expression. BDL rats also exhibit renal and brain damage characterized by increased tissue ADMA concentrations. The increased plasma ADMA levels and multiple organ damages seen here are also observed following multiple organ failures associated with critical illness. This review discusses the dysregulation of ADMA in major organs in BDL rats and the role of increased ADMA in multiple organ damages.
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Affiliation(s)
- Jiunn-Ming Sheen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Yu-Chieh Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - You-Lin Tain
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Li-Tung Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
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Karagiannakis DS, Vlachogiannakos J, Anastasiadis G, Vafiadis-Zouboulis I, Ladas SD. Frequency and severity of cirrhotic cardiomyopathy and its possible relationship with bacterial endotoxemia. Dig Dis Sci 2013; 58:3029-36. [PMID: 23907333 DOI: 10.1007/s10620-013-2693-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 04/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The cardiac dysfunction presented in cirrhotic patients is already known as cirrhotic cardiomyopathy. The pathogenesis of this entity is not fully understood. AIMS The aim of this study was to evaluate the frequency and characteristics of cirrhotic cardiomyopathy and to investigate the possible role of bacterial endotoxemia on its aggravation. METHODS Forty-five cirrhotics were studied by a tissue Doppler imaging echocardiography at rest and after stress. The diagnosis of left ventricular diastolic dysfunction was based on the latest guidelines of the American Society of Echocardiography, whereas its severity was defined by the E/e'av ratio. Endotoxemia was estimated by measuring the serum levels of lipopolysaccharide-binding protein (LBP) and cytokines. RESULTS None of the patients had systolic dysfunction, but 17/45 (37.8 %) had a diastolic one. Patients with grade II diastolic dysfunction had significantly longer QTc (p = 0.049), larger left atrium volume (p = 0.013), higher Brain Natriuretic Peptide levels (p = 0.007) and higher LBP levels (p = 0.02), compared to those with normal cardiac function, without differences in the systemic hemodynamics and the cytokines' levels. Moreover, the severity of diastolic dysfunction as reflected by the E/e'av. was significantly correlated with the LBP levels (p = 0.002). On the multivariate analysis, the LBP was independently associated with the presence of diastolic dysfunction. CONCLUSIONS Cirrhosis is commonly complicated by cardiac dysfunction. Patients with severe cirrhotic cardiomyopathy have higher LBP levels, which are significantly correlated with the degree of diastolic dysfunction. Our findings support a potential role of bacterial endotoxemia on the aggravation of cardiomyopathy in cirrhotic patients.
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Affiliation(s)
- Dimitrios S Karagiannakis
- Hepatogastroenterology Unit, 1st Department of Medicine Propaedeutic, Medical School of Athens, Laikon General Hospital, 17 Agiou Thoma Street, 11527, Athens, Greece,
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