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Li Y, Li J, Leng A, Zhang G, Qu J. Cardiac complications caused by biliary diseases: A review of clinical manifestations, pathogenesis and treatment strategies of cholecardia syndrome. Pharmacol Res 2024; 199:107006. [PMID: 38000562 DOI: 10.1016/j.phrs.2023.107006] [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: 08/02/2023] [Revised: 10/19/2023] [Accepted: 11/19/2023] [Indexed: 11/26/2023]
Abstract
Gallbladder and biliary diseases (GBDs) are one of the most common digestive diseases. The connections between GBDs and several organs other than the liver have gradually surfaced accompanied by the changes in people's diet structure and the continuous improvement of medical diagnosis technology. Among them, cholecardia syndrome that takes the heart as the important target of GBDs complications has been paid close attention. However, there are still no systematic report about its corresponding clinical manifestations and pathogenesis. This review summarized recent reported types of cholecardia syndrome and found that arrhythmia, myocardial injury, acute coronary syndrome and heart failure are common in the general population. Besides, the clinical diagnosis rate of intrahepatic cholestasis of pregnancy (ICP) and Alagille syndrome associated with gene mutation is also increasing. Accordingly, the underlying pathogenesis including abnormal secretion of bile acid, gene mutation, translocation and deletion (JAG1, NOTCH2, ABCG5/8 and CYP7A1), nerve reflex and autonomic neuropathy were further revealed. Finally, the potential treatment measures and clinical medication represented by ursodeoxycholic acid were summarized to provide assistance for clinical diagnosis and treatment.
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Affiliation(s)
- Yanan Li
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China
| | - Jinghong Li
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China
| | - Aijing Leng
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Guixin Zhang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China.
| | - Jialin Qu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China.
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Zhan Y, Xu T, Chen T, Deng X, Kong Y, Li Y, Wang X. Intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100952. [PMID: 37023984 DOI: 10.1016/j.ajogmf.2023.100952] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/15/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes. Fetal cardiac dysfunction may be 1 part of the pathophysiology of pregnancies complicated by intrahepatic cholestasis of pregnancy. This systematic review and meta-analysis aimed to evaluate the association between intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction. DATA SOURCES Systematic searches were performed on the databases of Medline, Embase, and Cochrane Library (up to March 2, 2023) for studies evaluating fetal cardiac function in pregnancies complicated by intrahepatic cholestasis of pregnancy in addition to the reference lists of included studies. STUDY ELIGIBILITY CRITERIA Studies were eligible for inclusion if they assessed the fetal cardiac function by fetal echocardiography in women with intrahepatic cholestasis of pregnancy (mild or severe) and compared with fetuses of healthy pregnant women. The studies published in English were included. METHODS The quality of the retrieved studies was assessed using the Newcastle-Ottawa Scale. Data on fetal myocardial performance index, E wave/A wave peak velocities ratio, and PR interval were pooled for the meta-analysis using random-effects models. The results were presented as weighted mean differences and 95% confidence intervals. This meta-analysis was registered with the International Prospective Register of Systematic Reviews (registration number: CRD42022334801). RESULTS A total of 14 studies were included in this qualitative analysis. Of note, 10 studies that reported data on fetal myocardial performance index, E wave/A wave peak velocities ratio, and PR interval were included in the quantitative analysis and showed a significant association between intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction. Significantly higher fetal left ventricular myocardial performance index values (weighted mean difference, 0.10; 95% confidence interval, 0.04-0.16) and longer fetal PR intervals (weighted mean difference, 10.10 ms; 95% confidence interval, 7.34-12.86) were revealed in pregnancies complicated by intrahepatic cholestasis of pregnancy. Compared with the situation in pregnancies complicated by mild intrahepatic cholestasis of pregnancy, PR intervals were even longer in pregnancies complicated by severe intrahepatic cholestasis of pregnancy (weighted mean difference, 5.98 ms; 95% confidence interval, 0.20-11.77). There was no significant difference in fetal E wave/A wave peak velocities ratio between the group with intrahepatic cholestasis of pregnancy and the healthy pregnant group (weighted mean difference, 0.01; 95% confidence interval, -0.03 to 0.05). CONCLUSION Our findings supported the idea that intrahepatic cholestasis of pregnancy is associated with overall impaired fetal myocardial performance and impaired fetal cardiac conduction system. However, current evidence about the association between fetal cardiac dysfunction and intrahepatic cholestasis of pregnancy-induced stillbirth is lacking. Further studies are needed to reveal the relationship between fetal cardiac dysfunction and adverse perinatal outcomes in pregnancies complicated by intrahepatic cholestasis of pregnancy.
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Affiliation(s)
- Yongchi Zhan
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang)
| | - Tingting Xu
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang)
| | - Tiantian Chen
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang)
| | - Xixi Deng
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang)
| | - Yao Kong
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang)
| | - Yaqian Li
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang)
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, Sichuan University West China Second University Hospital, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang); Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China (Zhan, Xu, Chen, Deng, Kong, Li and Wang).
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Wang J, Lun W, Shi W. Effects of elevated bile acid levels on fetal myocardium in intrahepatic cholestasis of pregnancy, a retrospective study from a neonatal perspective. Clin Res Hepatol Gastroenterol 2022; 46:102013. [PMID: 36044978 DOI: 10.1016/j.clinre.2022.102013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/27/2022] [Accepted: 08/24/2022] [Indexed: 02/04/2023]
Abstract
AIM Intrahepatic cholestasis of pregnancy (ICP) is a liver disease which may lead to a sudden fetal death.Previous studies have suggested that the fetal accident may be related to their cardiac dysfunction.However,the relationship between fetal cardiac dysfunction and their maternal bile acid levels is not clear.This objective was to clarify the relationship from a neonatal perspective and to furtherly make clear the aftereffect by analyzing the cardiac parameters of the older neonates. METHODS In this case-control study,patients and their neonates,managed between 10 September 2018 and 30 June 2021 at a Chinese university hospital center,were divided into severe ICP group,mild ICP group and control gestational group.The maternal bile acid levels and the cardiac paramerers of one-day-old neonates and five-day-old neonates were analyzed,respectively. RESULTS The specific-myocardial enzyme(CK-MB) and left ventricular fraction shortening(FS) of neonates showed significant difference between ICP group and control group, and were meaningfully correlated with maternal bile acid levels.However,There was no significant difference in cardiac injury parameters of older neonates between the ICP group and control group. CONCLUSIONS The elevated maternal bile acid levels can lead to fetal myocardial injury and the injury can be recovered after removel from high concentrations of bile acid.
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Affiliation(s)
- Junnai Wang
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, He' nan 450052, China.
| | - Weiwei Lun
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, He' nan 450052, China
| | - Wei Shi
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, He' nan 450052, China
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Hagenbeck C, Hamza A, Kehl S, Maul H, Lammert F, Keitel V, Hütten MC, Pecks U. Management of Intrahepatic Cholestasis of Pregnancy: Recommendations of the Working Group on Obstetrics and Prenatal Medicine - Section on Maternal Disorders. Geburtshilfe Frauenheilkd 2021; 81:922-939. [PMID: 34393256 PMCID: PMC8354365 DOI: 10.1055/a-1386-3912] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease specific to pregnancy. The cardinal symptom of pruritus and a concomitant elevated level of bile acids in the serum and/or alanine aminotransferase (ALT) are suggestive for the diagnosis. Overall, the maternal prognosis is good. The fetal outcome depends on the bile acid level. ICP is associated with increased risks for adverse perinatal outcomes, including preterm delivery, meconium-stained amniotic fluid, and stillbirth. Acute fetal asphyxia and not chronic uteroplacental dysfunction leads to stillbirth. Therefore, predictive fetal monitoring is not possible. While medication with ursodeoxycholic acid (UDCA) improves pruritus, it has not been shown to affect fetal outcome. The indication for induction of labour depends on bile acid levels and gestational age. There is a high risk of recurrence in subsequent pregnancies.
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Affiliation(s)
| | - Amr Hamza
- Universitätsklinikum des Saarlandes, Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Homburg, Germany
- Kantonsspital Baden AG, Baden, Switzerland
| | - Sven Kehl
- Frauenklinik, Friedrich Alexander University Erlangen Nuremberg, Faculty of Medicine, Erlangen, Germany
| | - Holger Maul
- Section of Prenatal Disgnostics and Therapy, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Frank Lammert
- Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Verena Keitel
- Universitätsklinikum Düsseldorf, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Düsseldorf, Germany
| | - Matthias C. Hütten
- Clinique E2 Neonatology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Ulrich Pecks
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Gynäkologie und Geburtshilfe, Kiel, Germany
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Vasavan T, Deepak S, Jayawardane IA, Lucchini M, Martin C, Geenes V, Yang J, Lövgren-Sandblom A, Seed PT, Chambers J, Stone S, Kurlak L, Dixon PH, Marschall HU, Gorelik J, Chappell L, Loughna P, Thornton J, Pipkin FB, Hayes-Gill B, Fifer WP, Williamson C. Fetal cardiac dysfunction in intrahepatic cholestasis of pregnancy is associated with elevated serum bile acid concentrations. J Hepatol 2021; 74:1087-1096. [PMID: 33276032 PMCID: PMC8062912 DOI: 10.1016/j.jhep.2020.11.038] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND & AIMS Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of stillbirth. This study aimed to assess the relationship between bile acid concentrations and fetal cardiac dysfunction in patients with ICP who were or were not treated with ursodeoxycholic acid (UDCA). METHODS Bile acid profiles and NT-proBNP, a marker of ventricular dysfunction, were assayed in umbilical venous serum from 15 controls and 76 ICP cases (36 untreated, 40 UDCA-treated). Fetal electrocardiogram traces were obtained from 43 controls and 48 ICP cases (26 untreated, 22 UDCA-treated). PR interval length and heart rate variability (HRV) parameters were measured in 2 behavioral states (quiet and active sleep). RESULTS In untreated ICP, fetal total serum bile acid (TSBA) concentrations (r = 0.49, p = 0.019), hydrophobicity index (r = 0.20, p = 0.039), glycocholate concentrations (r = 0.56, p = 0.007) and taurocholate concentrations (r = 0.44, p = 0.039) positively correlated with fetal NT-proBNP. Maternal TSBA (r = 0.40, p = 0.026) and alanine aminotransferase (r = 0.40, p = 0.046) also positively correlated with fetal NT-proBNP. There were no significant correlations between maternal or fetal serum bile acid concentrations and fetal HRV parameters or NT-proBNP concentrations in the UDCA-treated cohort. Fetal PR interval length positively correlated with maternal TSBA in untreated (r = 0.46, p = 0.027) and UDCA-treated ICP (r = 0.54, p = 0.026). Measures of HRV in active sleep and quiet sleep were significantly higher in untreated ICP cases than controls. HRV values in UDCA-treated cases did not differ from controls. CONCLUSIONS Elevated fetal and maternal serum bile acid concentrations in untreated ICP are associated with an abnormal fetal cardiac phenotype characterized by increased NT-proBNP concentration, PR interval length and HRV. UDCA treatment partially attenuates this phenotype. LAY SUMMARY The risk of stillbirth in intrahepatic cholestasis of pregnancy (ICP) is linked to the level of bile acids in the mother which are thought to disrupt the baby's heart rhythm. We found that babies of women with untreated ICP have abnormally functioning hearts compared to those without ICP, and the degree of abnormality is closely linked to the level of harmful bile acids in the mother and baby's blood. Babies of women with ICP who received treatment with the drug UDCA do not have the same level of abnormality in their hearts, suggesting that UDCA could be a beneficial treatment in some ICP cases, although further clinical trials are needed to confirm this.
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Affiliation(s)
- Tharni Vasavan
- Department of Women and Children’s Health, King's College London, London, UK
| | - Sahil Deepak
- Department of Women and Children’s Health, King's College London, London, UK
| | - Indu Asanka Jayawardane
- University Department of Obstetrics and Gynaecology, Nottingham City Hospital, University of Nottingham, Nottingham, UK,Faculty of Engineering, University of Nottingham, Nottingham, UK
| | - Maristella Lucchini
- Departments of Psychiatry and Pediatrics, Columbia University, New York, USA
| | - Catherine Martin
- Department of Women and Children’s Health, King's College London, London, UK
| | - Victoria Geenes
- Department of Women and Children’s Health, King's College London, London, UK
| | - Joel Yang
- Departments of Psychiatry and Pediatrics, Columbia University, New York, USA
| | | | - Paul Townsend Seed
- Department of Women and Children’s Health, King's College London, London, UK
| | - Jenny Chambers
- Women’s Health Research Centre, Imperial College London, London, UK
| | - Sophia Stone
- Department of Obstetrics and Gynaecology, Western Sussex Hospitals NHS Foundation Trust, West Sussex, UK
| | - Lesia Kurlak
- University Department of Obstetrics and Gynaecology, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - Peter Hendy Dixon
- Department of Women and Children’s Health, King's College London, London, UK
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Julia Gorelik
- Imperial College London, National Heart and Lung Institute, Imperial Centre for Experimental and Translational Medicine, London, UK
| | - Lucy Chappell
- Department of Women and Children’s Health, King's College London, London, UK
| | - Pam Loughna
- University Department of Obstetrics and Gynaecology, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - Jim Thornton
- University Department of Obstetrics and Gynaecology, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - Fiona Broughton Pipkin
- University Department of Obstetrics and Gynaecology, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | | | - William Paul Fifer
- Departments of Psychiatry and Pediatrics, Columbia University, New York, USA
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