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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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Wray CL, Xia VW, Ershoff BD, Fields S, Scovotti JC, Grogan T, Honda HM, Kaldas FM. Utility of preoperative troponin I to predict mortality in adult liver transplant recipients: Revisiting pretransplant cardiac risk in the current MELD-allocation era. Clin Transplant 2024; 38:e15191. [PMID: 37965869 DOI: 10.1111/ctr.15191] [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: 08/18/2023] [Revised: 09/26/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Preoperative risk assessment in liver transplant (LT) candidates, particularly related to cardiac risk, is an area of intense interest for transplant clinicians. Various cardiac testing methods are employed by transplant centers to characterize cardiac risk. Serum troponin is an established method for the detection of myocardial injury in a wide variety of clinical settings. Preoperative troponin screening has been reported to predict postoperative cardiac events and mortality in various surgical patient populations, however, the utility of preoperative troponin to predict posttransplant outcomes in current LT candidate populations requires further investigation. METHODS We performed a prospective blinded study in a cohort of 275 consecutive LT recipients at a single transplant center to determine if preoperative serum troponin I (TnI) was predictive for postoperative 1-year mortality. RESULTS Abnormal preoperative TnI levels (>.1 ng/mL) were found in 38 patients (14%). One-year mortality occurred in 19 patients (7%). There was no significant difference in mortality between patients with normal and abnormal troponin levels. Additionally, we found that there was no significant difference in early postoperative major adverse cardiac events between patient groups. CONCLUSIONS Contrary to previous reports, elevated preoperative TnI was not significantly predictive of posttransplant mortality in LT recipients at our institution.
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Affiliation(s)
- Christopher L Wray
- Departments of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Victor W Xia
- Departments of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Brent D Ershoff
- Departments of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Sherri Fields
- Departments of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jennifer C Scovotti
- Departments of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Tristan Grogan
- Departments of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Henry M Honda
- Departments of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Fady M Kaldas
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Mani I, Alexopoulos T, Vasilieva L, Alexopoulou A. Serum troponin is elevated in acute decompensation and acute-on-chronic liver failure and is associated with severity of liver disease and short-term mortality. Scand J Gastroenterol 2022:1-7. [PMID: 36424717 DOI: 10.1080/00365521.2022.2131333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of high sensitive cardiac Troponin (hs-cTn) in patients with liver cirrhosis (LC) and liver-related acute events is not well established. AIM To assess the prognostic performance of hs-cTn I in acute decompensation (AD) and acute-on-chronic liver failure (ACLF). METHODS Two cohorts of consecutive patients, a derivation (retrospective) and a validation (prospective), were evaluated and 30-day-mortality was recorded. Hs-cTnI values were measured. Very low hs-cTnΙ (4 ng/L) was considered the cutoff-level. RESULTS A total of 296 patients with LC [69.3% male, median age 57 (IQR 51-68) years, MELD score 19 (13-25), ACLF (29.4%), AD (48.3%), and without liver-related acute events (22.3%)] were included in the derivation cohort. The 66.2% of total patients had hs-cTnI ≥4 ng/L. Patients with hs-cTnI ≥4 ng/L were older and had more severe LC compared to those with <4ng/L. The multivariate analysis demonstrated that age (p < 0.001) and MELD (p = 0.001) were independent variables associated with elevated hs-cTnI after adjustment for age, sex and hepatic encephalopathy in total patients.When ACLF and AD were analyzed separately, the mortality was higher in patients with hs-cTnI ≥ 4 ng/L compared to lower values (log-rank p = 0.036 and p = 0.019, respectively). In multivariate analysis, MELD (p < 0.001) and hs-cTnI ≥4 ng/L (p = 0.032) were independent prognostic factors of mortality in ACLF/AD groups, after adjustment for age and sex. Similar results were obtained from the validation cohort (N = 148). CONCLUSIONS hs-cTnI levels were higher in patients with severe liver disease. The low cutoff-point of 4 ng/L is accurate in ruling out non-survivors mainly in AD group.
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Affiliation(s)
- Iliana Mani
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Theodoros Alexopoulos
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | | | - Alexandra Alexopoulou
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Uhlig M, Hein M, Habigt MA, Tolba RH, Braunschweig T, Helmedag MJ, Klinge U, Koch A, Trautwein C, Mechelinck M. Acute myocardial injury secondary to severe acute liver failure: A retrospective analysis supported by animal data. PLoS One 2021; 16:e0256790. [PMID: 34460845 PMCID: PMC8405020 DOI: 10.1371/journal.pone.0256790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/17/2021] [Indexed: 11/29/2022] Open
Abstract
To investigate whether acute liver failure (ALF) leads to secondary acute myocardial injury, 100 ALF patients that were retrospectively identified in a single center based on ICD 10 codes and 8 rats from an experimental study that died early after bile duct ligation (BDL) were examined. Creatine kinase (CK), creatine kinase-MB isoenzyme (CKMB) and cardiac troponin-I (cTnI) were analyzed as markers of myocardial injury. For histological analysis, hematoxylin-eosin (HE), elastic Van Gieson (EVG), CD41 and myeloperoxidase were used to stain rat hearts. Major adverse cardiac events (MACEs) were a critical factor for mortality (p = 0.037) in human ALF. Deceased patients exhibited higher levels of CKMB than survivors (p = 0.023). CKMB was a predictor of mortality in ALF (p = 0.013). Animals that died early after BDL exhibited increased cTnI, CKMB, tumor necrosis factor α (TNFα) and interleukin-6 (IL-6) levels compared to controls (cTnI: p = 0.011, CKMB: p = 0.008, TNFα: p = 0.003, IL-6: p = 0.006). These animals showed perivascular lesions and wavy fibers, microthrombi and neutrophilic infiltration in the heart. MACEs are decisive for mortality in human ALF, and elevated CKMB values indicate that this might be due to structural myocardial damage. Accordingly, CKMB was found to have predictive value for mortality in ALF. The results are substantiated by data from a rat BDL model demonstrating diffuse myocardial injury.
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Affiliation(s)
- Moritz Uhlig
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Marc Hein
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Moriz A. Habigt
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - René H. Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Till Braunschweig
- Department of Pathology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Marius J. Helmedag
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Uwe Klinge
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Alexander Koch
- Department of Gastroenterology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Christian Trautwein
- Department of Gastroenterology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Mare Mechelinck
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Institute for Laboratory Animal Science and Experimental Surgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
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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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Raane M, Eberl M, Möbius J, Umgelter A. Second Look: The Predictive Value of Elevated Cardiac Troponins Often Depends on Retesting. Acad Emerg Med 2020; 27:644-645. [PMID: 32412107 DOI: 10.1111/acem.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/04/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Maximilian Raane
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany
| | - Marcel Eberl
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany
| | - Julia Möbius
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany
| | - Andreas Umgelter
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany.,Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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Blažek P, Ferri-Certić J, Vražić H, Lennerz C, Grebmer C, Kaitani K, Karch M, Starčević B, Semmler V, Kolb C. Pacemaker Implantation Associated Myocardial Micro-Damage: A Randomised Comparison between Active and Passive Fixation Leads. Sci Rep 2018; 8:4870. [PMID: 29559697 PMCID: PMC5861101 DOI: 10.1038/s41598-018-23209-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/07/2018] [Indexed: 12/24/2022] Open
Abstract
Fixation of the pacemaker leads during pacemaker implantation leads to an increase of cardiac Troponin T (cTnT) that can be interpreted as a sign of minimal myocardial damage. This trial evaluates whether the mechanism type of lead fixation influences the magnitude of cTnT release. Patients having a de-novo cardiac pacemaker implantation or a lead revision were centrally randomized to receive either a ventricular lead with an active (screw) or passive (tine) fixation mechanism. High-sensitive Troponin T (hsTnT) was determined on the day of the procedure beforehand and on the following day. 326 Patients (median age (IQR) 75.0 (69.0–80.0) years, 64% male) from six international centers were randomized to receive ventricular leads with an active (n = 166) or passive (n = 160) fixation mechanism. Median (IQR) hsTnT levels increased by 0.009 (0.004–0.021) ng/ml in the group receiving screw-in ventricular leads and by 0.008 (0.003–0.030) ng/ml in the group receiving tined ventricular leads (n.s.). In conclusion pacemaker implantations are followed by a release of hsTnT. The choice between active or passive fixation ventricular leads does not have a significant influence on the extent of myocardial injury and the magnitude of hsTnT release.
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Affiliation(s)
- Patrick Blažek
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung für Elektrophysiologie, Fakultät für Medizin der Technischen Universität München, Munich, Germany.
| | | | - Hrvoje Vražić
- University Hospital Dubrava, Division of Cardiology, Department of Internal Medicine, Zagreb, Croatia
| | - Carsten Lennerz
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung für Elektrophysiologie, Fakultät für Medizin der Technischen Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Christian Grebmer
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung für Elektrophysiologie, Fakultät für Medizin der Technischen Universität München, Munich, Germany
| | | | - Martin Karch
- Klinikverbund Kempten-Oberallgäu, Abteilung für Kardiologie, Kempten, Germany
| | - Boris Starčević
- University Hospital Dubrava, Division of Cardiology, Department of Internal Medicine, Zagreb, Croatia
| | - Verena Semmler
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung für Elektrophysiologie, Fakultät für Medizin der Technischen Universität München, Munich, Germany
| | - Christof Kolb
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Abteilung für Elektrophysiologie, Fakultät für Medizin der Technischen Universität München, Munich, Germany
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