Cirrhotic cardiomyopathy: the liver affects the heart

Prevalence and risk factors for cirrhotic cardiomyopathy: a prospective cross-sectional study

BACKGROUND

This study aimed to assess cardiac structure and function in patients with cirrhosis, to investigate the prevalence of cirrhotic cardiomyopathy (CCM) in patients with cirrhosis of different etiologies and to analyze the risk factors for the development of CCM.

METHODS

This study selected cirrhotic patients aged 18-75 years who were hospitalized in Qilu Hospital of Shandong University. Patients with known heart disease, chronic lung disease, severe renal insufficiency, malignancy, thyroid disease, hypertension, diabetes or pregnancy were excluded. A total of 131 patients with cirrhosis were finally included. Based on the results of echocardiography, patients who met the diagnostic definition of CCM were included in the CCM group, otherwise, they were classified as the non-CCM group. The demographic and clinical data of the two groups were compared, and the clinical characteristics and risk factors of CCM were evaluated.

RESULTS

The overall prevalence of CCM was 24.4%, and the occurrence of CCM was not related to the etiology of liver cirrhosis. The prevalence of CCM was significantly higher among cirrhotic patients complicated with ascites (31.4% vs. 16.4%; P  = 0.046) or with portal vein thrombosis (PVT) (42.9% vs. 17.1%; P  = 0.003). Older age [odds ratio (OR) = 1.058; 95% confidence interval (CI), 1.005-1.113; P  = 0.032] and PVT (OR = 2.999; 95% CI, 1.194-7.533; P  = 0.019) were independent risk factors for the development of CCM.

CONCLUSION

The prevalence of CCM in cirrhotic patients was 24.4%, and the occurrence of CCM was not related to the etiology of cirrhosis. The prevalence of CCM was higher in cirrhotic patients with ascites or PVT. Older age and PVT are independent risk factors for CCM, but validation in larger sample studies is still needed.

Review on Kidney-Liver Crosstalk: Pathophysiology of Their Disorders

Kidney-liver crosstalk plays a crucial role in normal and certain pathological conditions. In pathologic states, both renal-induced liver damage and liver-induced kidney diseases may happen through these kidney-liver interactions. This bidirectional crosstalk takes place through the systemic conditions that mutually influence both the liver and kidneys. Ischemia and reperfusion, cytokine release and pro-inflammatory signaling pathways, metabolic acidosis, oxidative stress, and altered enzyme activity and metabolic pathways establish the base of this interaction between the kidneys and liver. In these concomitant kidney-liver diseases, the survival rates strongly correlate with early intervention and treatment of organ dysfunction. Proper care of a nephrologist and hepatologist and the identification of pathological conditions using biomarkers at early stages are necessary to prevent the complications induced by this complex and potentially vicious cycle. Therefore, understanding the characteristics of this crosstalk is essential for better management. In this review, we discussed the available literature concerning the detrimental effects of kidney failure on liver functions and liver-induced kidney diseases.

Hepatocardiorenal syndrome in liver cirrhosis: Recognition of a new entity?

Emerging evidence and perspectives have pointed towards the heart playing an important role in hepatorenal syndrome (HRS), outside of conventional understanding that liver cirrhosis is traditionally considered the sole origin of a cascade of pathophysiological mechanisms directly affecting the kidneys in this context. In the absence of established heart disease, cirrhotic cardiomyopathy may occur more frequently in those with liver cirrhosis and kidney disease. It is a specific form of cardiac dysfunction characterized by blunted contractile responsiveness to stress stimuli and altered diastolic relaxation with electrophysiological abnormalities. Despite the clinical description of these potential cardiac-related complications of the liver, the role of the heart has traditionally been an overlooked aspect of circulatory dysfunction in HRS. Yet from a physiological sense, temporality (prior onset) of cardiorenal interactions in HRS and positive effects stemming from portosystemic shunting demonstrated an important role of the heart in the development and progression of kidney dysfunction in cirrhotic patients. In this review, we discuss current concepts surrounding how the heart may influence the development and progression of HRS, and the role of systemic inflammation and endothelial dysfunction causing circulatory dysfunction within this setting. The temporality of heart and kidney dysfunction in HRS will be discussed. For a subgroup of patients who receive portosystemic shunting, the dynamics of cardiorenal interactions following treatment is reviewed. Continued research to determine the unknowns in this topic is anticipated, hopefully to further clarify the intricacies surrounding the liver-heart-kidney connection and improve strategies for management.

Life-Threatening Electrical Storm Following Liver Transplantation: A Case Report

BACKGROUND Electrical storm is a rare but potentially life-threatening syndrome characterized by recurrent ventricular arrhythmias. Liver transplant recipients are at increased risk of developing electrical storms due to conditions that prolong QT intervals, such as cirrhotic cardiomyopathy. However, limited information exists on electrical storms in this specific population. This case report presents a patient who experienced 13 cardiac arrests during ventricular fibrillation following liver transplantation. CASE REPORT A 61-year-old woman with a medical history of diabetes, obesity, and cirrhosis due to non-alcoholic fatty liver disease underwent liver transplantation using a deceased donor's liver. Following the procedure, she developed a deterioration in her respiratory function, necessitating orotracheal intubation. Approximately 21 hours post-surgery, she experienced cardiac arrest during ventricular fibrillation, which was rapidly reversed with electrical defibrillation. However, the patient entered a state of electrical storm. Management involved antiarrhythmic medications and temporary transvenous cardiac pacing. She remained stable for 40 hours, but a dislodgment of the device triggered another episode of ventricular fibrillation, leading to her death. CONCLUSIONS This case report highlights the clinical presentation and challenges in managing electrical storms in liver transplant recipients. We hypothesize that cirrhotic cardiomyopathy could be the cause of her recurrent ventricular arrhythmias. Further studies are needed to better understand the underlying mechanisms and risk factors of this life-threatening syndrome in this population, which may enhance risk stratification and enable earlier intervention.

Corrected QT interval in cirrhosis: A systematic review and meta-analysis

BACKGROUND

Corrected QT (QTc) interval is prolonged in patients with liver cirrhosis and has been proposed to correlate with the severity of the disease. However, the effects of sex, age, severity, and etiology of cirrhosis on QTc have not been elucidated. At the same time, the role of treatment, acute illness, and liver transplantation (Tx) remains largely unknown.

AIM

To determine the mean QTc in patients with cirrhosis, assess whether QTc is prolonged in patients with cirrhosis, and investigate whether QTc is affected by factors such as sex, age, severity, etiology, treatment, acute illness, and liver Tx.

METHODS

In the present systematic review and meta-analysis, the searching protocol "{[QTc] OR [QT interval] OR [QT-interval] OR [Q-T syndrome]} AND {[cirrhosis] OR [Child-Pugh] OR [MELD]}" was applied in PubMed, EMBASE, and Google Scholar databases to identify studies that reported QTc in patients with cirrhosis and published after 1998. Seventy-three studies were considered eligible. Data concerning first author, year of publication, type of study, method used, sample size, mean age, female ratio, alcoholic etiology of cirrhosis ratio, Child-Pugh A/B/C ratio, mean model for end-stage liver disease (MELD) score, treatment with β-blockers, episode of acute gastrointestinal bleeding, formula for QT correction, mean pulse rate, QTc in patients with cirrhosis and controls, and QTc according to etiology of cirrhosis, sex, Child-Pugh stage, MELD score, and liver Tx status (pre-Tx/post-Tx) were retrieved. The Newcastle-Ottawa quality assessment scale appraised the quality of the eligible studies. Effect estimates, expressed as proportions or standardized mean differences, were combined using the random-effects, generic inverse variance method of DerSimonian and Laird. Subgroup, sensitivity analysis, and meta-regressions were applied to assess heterogeneity. The study has been registered in the PROSPERO database (CRD42023416595).

RESULTS

QTc combined mean in patients with cirrhosis was 444.8 ms [95% confidence interval (CI): 440.4-449.2; P < 0.001 when compared with the upper normal limit of 440 ms], presenting high heterogeneity (I2 = 97.5%; 95%CI: 97.2%-97.8%); both Egger's and Begg's tests showed non-significance. QTc was elongated in patients with cirrhosis compared with controls (P < 0.001). QTc was longer in patients with Child-Pugh C cirrhosis when compared with Child-Pugh B and A (P < 0.001); Child-Pugh B patients presented longer QTc when compared with Child-Pugh A patients (P = 0.003). The MELD score was higher in patients with cirrhosis with QTc > 440 ms when compared with QTc ≤ 440 ms (P < 0.001). No correlation of QTc with age (P = 0.693), sex (P = 0.753), or etiology (P = 0.418) was detected. β-blockers shortened QTc (P< 0.001). QTc was prolonged during acute gastrointestinal bleeding (P = 0.020). Tx tended to improve QTc (P < 0.001). No other sources of QTc heterogeneity were revealed.

CONCLUSION

QTc is prolonged in cirrhosis independently of sex, age, and etiology but is correlated with severity and affected by β-blockers and acute gastrointestinal bleeding. QTc is improved after liver Tx.

Flow Dynamic Pattern in Liver and Renal Transplantation under Exercise Prescription Program

BACKGROUND

Cardiovascular diseases in the context of renal and liver transplants remain the leading cause of morbidity and mortality. Physical exercise at a moderate intensity is allowed to contrast the risk profile. Echocardiographic evaluation is essential to stratifying potential cardiotoxicity by the standard and, more recently, the deformation and dynamic study of the intracardiac vortex. This study aims to investigate the vortex echo parameters of solid-organ-transplanted subjects who are physically active compared to a control group of healthy subjects.

METHODS

A group of 33 transplanted subjects (16 kidneys and 17 livers) was studied via a transthoracic echocardiography exam, comprehending the myocardial deformation parameters of global longitudinal strain (GLS), twisting of the left ventricle (LV) chamber, and HyperDoppler image acquisition.

RESULTS

The subjects enrolled in this study were 50 in total: there were 33 transplanted and 17 healthy subjects. The transplanted subjects presented higher values of interventricular septum in diastole (IVSd p = 0.001), posterior wall diastolic (PWd p = 0.05), and left ventricle mass index (LVMI p = 0.029); ejection fraction (EF) was found to be higher in athletes (p < 0.001). Transplanted subjects presented mild diastolic dysfunction, emerging only from septal E values (p = 0.001). The 4DStrain (p = 0.018) and GLS2c (p = 0.017) were significantly better in the athletes. All of the geometrical and energetical vortex data were in the normal range and no significant differences were found. An interesting positive correlation was evident for the diastolic parameter, particularly the E/A ratio (p = 0.023) and E' septal value (p = 0.049), along with the vorticity fluctuation. This behavior was present for all subjects, particularly those that were transplanted (p = 0.005).

CONCLUSIONS

In the vortex investigation, especially in cases of normal EF, the positive correlation of some diastolic parameters with the flow dynamic patterns corroborates this hypothesis. The HyperDoppler analysis could be helpful to detecting potential damage earlier in the diastolic time before a systolic deficiency.

Correlation analysis between myocardial work indices and liver function classification in patients with hepatitis B cirrhosis: A study with non-invasive left ventricular pressure-strain loop

Background

Liver cirrhosis is closely associated with cardiac dysfunction. The aims of this study were to evaluate left ventricular systolic function in patients with hepatitis B cirrhosis by non-invasive left ventricular pressure-strain loop (LVPSL) technique, and to explore the correlation between myocardial work indices and liver function classification.

Methods

According to the Child-Pugh classification, 90 patients with hepatitis B cirrhosis were further divided into three groups: Child-Pugh A group (n = 32), Child-Pugh B group (n = 31), and Child-Pugh C group (n = 27). During the same period, 30 healthy volunteers were recruited as the control (CON) group. Myocardial work parameters, which included global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), were derived from the LVPSL and compared among the four groups. The correlation between myocardial work parameters and Child-Pugh liver function classification was evaluated, and the independent risk factors affecting left ventricular myocardial work in patients with cirrhosis were investigated by univariable and multivariable linear regression analysis.

Results

GWI, GCW and GWE of Child-Pugh B and C groups were lower than those of CON group, while GWW was higher than that of CON group, and the changes were more obvious in Child-Pugh C group (P &lt; 0.05). Correlation analysis revealed that GWI, GCW, and GWE were negatively correlated with liver function classification to various degrees (r = −0.54, −0.57, and −0.83, respectively, all P &lt; 0.001), while GWW was positively correlated with liver function classification (r = 0.76, P &lt; 0.001). Multivariable linear regression analysis showed that GWE was positively correlated with ALB (β = 0.17, P &lt; 0.001), and negatively correlated with GLS (β = −0.24, P &lt; 0.001).

Conclusions

The changes in the left ventricular systolic function in patients with hepatitis B cirrhosis were identified using non-invasive LVPSL technology, and myocardial work parameters are significantly correlated with liver function classification. This technique may provide a new method for the evaluation of cardiac function in patients with cirrhosis.

Comprehensive evaluation of circRNAs in cirrhotic cardiomyopathy before and after liver transplantation

Cirrhotic cardiomyopathy (CCM) is a common complication of liver cirrhosis. Many patients with cirrhotic livers do not die from liver failure but from abnormal hemodynamics secondary to liver cirrhosis. Liver transplantation is one of the most effective treatments for liver diseases. Recent studies have found that liver transplantation can reverse CCM and improve cardiac function; however, its role and remedial mechanism remain unclear. Circular RNAs (circRNAs) have become an important marker for diagnosing diseases. The differential expression of circRNAs is associated with heart diseases. In this study, we used gene sequencing to detect the circRNA expression profile of patients with CCM before and after liver transplantation and predicted the differential circRNA target genes. The results showed that a total of 1495 circRNAs were dysregulated after liver transplantation, 1319 genes were downregulated, and 176 were upregulated (P < 0.05, log2 (fold change) > 2.0). The qRT-PCR results showed that circ-ASAP1, circ-N4BP2L2, circ-EXOC6B were significantly downregulated (P < 0.05), which were consistent with the RNA sequencing data, and circ-ASAP1 had the most significant difference. Bioinformatics analysis suggested that mTOR and MAPK signaling pathways might be involved in the pathogenesis of CCM. By constructing a circRNA-miRNA-mRNA interaction network, hsa-miR-197-3p, hsa-miR-483-3p, and hsa-miR-885-3p, particularly key miRNA (hsa-miR-483-3p), were found to be the major potential genes involved in CCM regulation. In summary, this study suggested that circRNAs play a crucial regulatory role in the occurrence of CCM before and after liver transplantation, and their potential biological function might be the key to diagnosis and treatment.

Postoperative Apical Ballooning Syndrome Following Orthotopic Liver Transplantation

As the mainstay of therapy for end-stage liver disease (ESLD), orthotopic liver transplantation (OLT) has complex effects on multiple organ systems. We present a representative case of acute heart failure with apical ballooning syndrome following OLT and review its mechanisms. Recognition of this and other potential cardiovascular and hemodynamic complications of OLT are essential to periprocedural anesthesia management. Once an acute phase of the condition is stabilized, conservative treatment and resolution of physical or emotional stressors usually allow for rapid resolution of symptoms, typically recovering systolic ventricular function within one to three weeks.

Alshamaa S. Evaluation of ejection fraction in patients with Acute Myocardial Infarction in Mosul City, Iraq

Between 1 January 2021 and 1 July 2021, 120 blood samples from acute myocardial infarction (AMI) patients—60 as controls and 60 patients—of both sexes who were accepted to the cardiac surgery unit at AL- Salam teaching hospital, the intensive cardiac care unit, and outpatient clinics in Mosul City/Iraq, were taken. In the presented research, the ejection fraction regarding patients with AMI was evaluated by echocardiography, and the blood-liver enzyme levels (ALP and AST \ ALT ratio) were examined in those patients. The findings indicate that patients with AMI in the age range of 35 to 45 years have a (52.41) % ejection fraction (EF) rate, which is closer to (51.344%) than it is in samples from healthy controls. In addition to that, findings indicate that patients in an age range of 46 to 56 years have heart failure with a mid-range EF (HFmrEF), with a (48.13%) percentage, whereas this heart failure type in healthy controls has been preserved ejection fraction (HFpEF) with (53.368 %). In the case of the comparison of the AST/ALT ratio and EF across all of the age groups that have been tested, the results suggest a significant level (P ≤ 0.050) relation between the ALP enzyme and EF for the patients within the (35-45 years) age group additionally, as there has been a positive and weak linear connection (r = 0.10650) and a nominal p-value (p = 0.47240) at a threshold of probability ≤ P 0.050, the link and correlation between the AST/ALT ratio and cardiac EF have been investigated. Keywords: ALP enzyme, AMI patients, Ejection Fraction, AST \ ALT ratio.

Phenotypic Disease Network-Based Multimorbidity Analysis in Idiopathic Cardiomyopathy Patients with Hospital Discharge Records

BACKGROUND

Idiopathic cardiomyopathy (ICM) is a rare disease affecting numerous physiological and biomolecular systems with multimorbidity. However, due to the small sample size of uncommon diseases, the whole spectrum of chronic disease co-occurrence, especially in developing nations, has not yet been investigated. To grasp the multimorbidity pattern, we aimed to present a multidimensional model for ICM and differences among age groups.

METHODS

Hospital discharge records were collected from a rare disease centre of ICM inpatients (n = 1036) over 10 years (2012 to 2021) for this retrospective analysis. One-to-one matched controls were also included. First, by looking at the first three digits of the ICD-10 code, we concentrated on chronic illnesses with a prevalence of more than 1%. The ICM and control inpatients had a total of 71 and 69 chronic illnesses, respectively. Second, to evaluate the multimorbidity pattern in both groups, we built age-specific cosine-index-based multimorbidity networks. Third, the associated rule mining (ARM) assessed the comorbidities with heart failure for ICM, specifically.

RESULTS

The comorbidity burden of ICM was 78% larger than that of the controls. All ages were affected by the burden, although those over 50 years old had more intense interactions. Moreover, in terms of disease connectivity, central, hub, and authority diseases were concentrated in the metabolic, musculoskeletal and connective tissue, genitourinary, eye and adnexa, respiratory, and digestive systems. According to the age-specific connection, the impaired coagulation function was required for raising attention (e.g., autoimmune-attacked digestive and musculoskeletal system disorders) in young adult groups (ICM patients aged 20-49 years). For the middle-aged (50-60 years) and older (≥70 years) groups, malignant neoplasm and circulatory issues were the main confrontable problems. Finally, according to the result of ARM, the comorbidities and comorbidity patterns of heart failure include diabetes mellitus and metabolic disorder, sleeping disorder, renal failure, liver, and circulatory diseases.

CONCLUSIONS

The main cause of the comorbid load is aging. The ICM comorbidities were concentrated in the circulatory, metabolic, musculoskeletal and connective tissue, genitourinary, eye and adnexa, respiratory, and digestive systems. The network-based approach optimizes the integrated care of patients with ICM and advances our understanding of multimorbidity associated with the disease.

Serum NT-ProBNP potential marker of cirrhotic cardiomyopathy

INTRODUCTION

Based on many previous studies, liver cirrhosis is traditionally associated with cardiac dysfunction. The main clinical features of cirrhotic cardiomyopathy include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities, and chronotropic incompetence. Previous studies have found that the levels of brain natriuretic peptide (BNP) and its precursor the N-terminal pro B-type natriuretic peptide (NT-proBNP) are elevated in cirrhosis with systolic as well as diastolic dysfunction.

Silymarin Administration Attenuates Cirrhotic-induced Cardiac Abnormality in the Rats: A Possible Role of β1-adrenergic Receptors and L-type Voltage-Dependent Calcium Channels

Background

Cirrhotic cardiomyopathy is a well-recognized cardiac dysfunction in cirrhotic patients. Studies have confirmed the protective effects of silymarin in different types of cardiac injury. This study aimed to examine the effectiveness and molecular mechanism of silymarin against myocardial dysfunction and hypertrophy in a rat model of cirrhosis.

Methods

The experiment was performed at Alborz University of Medical Sciences (Karaj, Iran) during 2020-2021. Thirty-two male Wistar rats were randomly divided into four groups of Sham-operated (control group for surgical procedures), Bile Duct Ligated (BDL), and two Silymarin extract (SE)-treated groups of 300 and 600 mg/Kg/day. After 28 days, serum levels of AST, ALT, GGT, and ALP, liver histopathological status, as well as cardiac mechanical function, were assessed. Cardiac β₁-adrenergic receptors (β₁-AR), L-type voltage-dependent calcium channels (L-VDCC), and GATA4 mRNA expression were also determined using real-time RT-PCR. Data analysis was performed using the one-way ANOVA followed by Duncan's multiple range test. Histological data has been analyzed with Kruskal-Wallis nonparametric test. The analysis was performed at P≤0.05.

Results

BDL was associated with a significant elevation in serum AST, ALT, GGT, and ALP, development of necrosis and fibrosis of the liver texture, increased Heart Weight and Heart Weight to Body Weight ratio, enhanced cardiac mechanical function as well as a significant up-regulation of ventricular β₁-AR and L-VDCC. Administration of SE600, but not SE300, significantly reduced the serum levels of the enzymes and alleviated signs of liver necrosis and fibrosis. Cirrhotic-induced cardiac dysfunction was also restored by SE600, but not by the lower dose. In addition, cardiac expression of the β₁-AR and L-VDCC was down-regulated toward normal values by either higher or lower doses of the SE.

Conclusion

Silymarin treatment in higher dose attenuated cirrhosis-associated cardiac remodeling and reduced cardiac mechanical dysfunctions.

A Case of Severe Tricuspid Valve Regurgitation in a Patient Undergoing Orthotopic Liver Transplantation: Whether to Proceed, or Not

A 38-year-old male presented for orthotopic liver transplantation complicated by new-onset torrential tricuspid regurgitation before incision. Subclinical volume overload and functional tricuspid regurgitation created a challenging scenario in which the benefits of expeditious transplant were weighed against the risks of allograft congestion and failure. Intraoperative transesophageal echocardiography proved critical in diagnosing severe tricuspid regurgitation and guided clinical decision making. In this article, we describe the intraoperative presentation of acutely elevated right heart pressures and the subsequent management of this patient prior to ultimately successful liver transplantation.

Biliary cirrhosis-induced cardiac abnormality in rats: Interaction between Farnesoid-X-activated receptors and the cardiac uncoupling proteins 2 and 3

OBJECTIVES

This study aimed to evaluate the relationship between Farnesoid-X-activated receptors (FXR) as nuclear regulators of the antioxidant defense system as well as cardiac mitochondrial carrier proteins of UCP2 and UCP3 in cardiac damage induced by cirrhosis.

MATERIALS AND METHODS

Twenty-two male Wistar rats (200-250 g) were randomly divided into 3 experimental groups, including a control group (n=6), a sham-operated group (n=8), and a bile duct ligated (BDL) group (n=8). Four weeks after surgical intervention, biochemical assessment (AST, ALT, GGT, LDH, and ALP), histological observation, and molecular evaluation (FXR, UCP2, UCP3, BNP, Caspase3, and GAPDH) using real-time RT-PCR were performed.

RESULTS

Compared with the sham-operation group, the BDL group showed a significant rise in liver enzymes of AST, ALT, GGT, LDH, and ALP. Defined fibrotic and necrotic bundles and thick reticulin fibers were also found in BDL liver tissue. Besides liver morphological alterations, left ventricles of BDL ones were also associated with defined cardiomyocyte hypertrophy, myofiber vacuolization, and clear pigmentation. Findings showed a significant up-regulation of cardiac Brain Natriuretic Peptide (BNP) along with marked down-regulation in hepatic FXR, cardiac FXR, and cardiac UCP2 and UCP3. However, the expression of caspase 3 in the cardiac tissue was not affected by BDL operation during 4 weeks.

CONCLUSION

Expression of FXR as an upstream regulator of cellular redox status, besides the non-enzymatic ROS buffering defense system of cardiac UCPs, has a pivotal role in the pathogenesis of cirrhotic-induced cardiac abnormality in rats.

Diagnosis and Management of Cirrhotic Cardiomyopathy

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.

Cardiac Complications of Common Drugs of Abuse: Pharmacology, Toxicology and Management

Cardiovascular complications from drugs of abuse are becoming more apparent due to increased usage worldwide. Substance abuse can cause both acute and chronic cardiovascular complications and is increasing in prevalence especially in young adults. These substances contribute to the development of acute coronary syndrome, type II myocardial injury, arrhythmias, cardiomyopathies and have numerous other cardiovascular complications. Although no screening guidelines exist, clinical awareness of these potential complications and their prevention, clinical presentation, diagnosis, and treatment are critically important. Management of cardiovascular disease should be coupled with appropriate social and mental health interventions to provide sustained clinical benefit. The higher the number of substances used recreationally, the greater the risk of premature heart disease. Epidemiological studies showed that 1 in 5 young adults misuse several substances and often start using at younger ages with a greater risk for adverse health outcomes over the long-term. The aim of this review is to highlight the basic epidemiology, cardiac complications, and disease-specific treatment options of commonly abused substances including methamphetamine, cocaine, alcohol, anabolic-androgenic steroids, cannabis, and tobacco.

Atrial fibrillation increases inpatient and 4-year all-cause mortality in critically ill patients with liver cirrhosis

Background

The association between atrial fibrillation (AF) and cirrhosis is unclear. Therefore, the aim of the present study was to determine the association between AF and short-term and 4-year mortality in critically ill patients with cirrhosis using a large database.

Methods

The Medical Information Mart for Intensive Care III (MIMIC III) database was used to identify patients with cirrhosis hospitalized in an intensive care unit from 2001 to 2012. Demographic and clinical data were extracted from the database. Clinical data and demographic information were collected for each patient in our study. Kaplan-Meier analysis and multivariate Cox regression models were performed to examine the relation between atrial fibrillation and in-hospital and 4-year all-cause mortality.

Results

A total of 1,481 patients (mean age: 58 years, 68% male) with liver cirrhosis were included in the analysis, and the prevalence of AF was 14.18%. The inpatient all-cause mortality rate was 26.6%, and patients who died in hospital had a significantly higher rate of AF (21.57% vs. 11.50%, P<0.001). Multivariate Cox regression analysis indicated that AF was significantly associated with inpatient all-cause mortality [hazard ratio (HR): 1.52, 95% confidence interval (CI): 1.19–1.95, P<0.001], and 4-year all-cause mortality (HR: 1.55, 95% CI: 1.12–2.13, P=0.008). Kaplan-Meier survival analysis showed that patients with AF had a significantly higher inpatient and 4-year all-cause mortality.

Conclusions

Critically ill patients with liver cirrhosis have a high rate of AF, and the presence of AF is an independent risk factor for inpatient and 4-year all-cause mortality.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Exercise Training Attenuates Cirrhotic Cardiomyopathy

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.

Hepatocardiac or Cardiohepatic Interaction: From Traditional Chinese Medicine to Western Medicine

There is a close relationship between the liver and heart based on "zang-xiang theory," "five-element theory," and "five-zang/five-viscus/five-organ correlation theory" in the theoretical system of Traditional Chinese Medicine (TCM). Moreover, with the development of molecular biology, genetics, immunology, and others, the Modern Medicine indicates the existence of the essential interorgan communication between the liver and heart (the heart and liver). Anatomically and physiologically, the liver and heart are connected with each other primarily via "blood circulation." Pathologically, liver diseases can affect the heart; for example, patients with end-stage liver disease (liver failure/cirrhosis) may develop into "cirrhotic cardiomyopathy," and nonalcoholic fatty liver disease (NAFLD) may promote the development of cardiovascular diseases via multiple molecular mechanisms. In contrast, heart diseases can affect the liver, heart failure may lead to cardiogenic hypoxic hepatitis and cardiac cirrhosis, and atrial fibrillation (AF) markedly alters the hepatic gene expression profile and induces AF-related hypercoagulation. The heart can also influence liver metabolism via certain nonsecretory cardiac gene-mediated multiple signals. Moreover, organokines are essential mediators of organ crosstalk, e.g., cardiomyokines link the heart to the liver, while hepatokines link the liver to the heart. Therefore, both TCM and Western Medicine, and both the basic research studies and the clinical practices, all indicate that there exist essential "heart-liver axes" and "liver-heart axes." To investigate the organ interactions between the liver and heart (the heart and liver) will help us broaden and deepen our understanding of the pathogenesis of both liver and heart diseases, thus improving the strategies of prevention and treatment in the future.

Evaluation of the effect of heat shock protein 70 targeted drugs on cirrhotic cardiomyopathy in biliary cirrhotic rats

AIMS

Liver cirrhosis leads to cirrhotic cardiomyopathy (CCM) and chronotropic incompetence (CI). Heat shock protein 70 (Hsp70) regulates cellular apoptosis and autophagy in stress. Teprenone modulates the Hsp70 and protects against cellular injury. Thus, we aimed to evaluate the effect of teprenone on CI in biliary cirrhotic rats.

MAIN METHODS

Liver cirrhosis was induced in male Wistar rats through bile duct ligation (BDL). The chronotropic responses and QT interval were studied through electrocardiography (ECG) in sham, cirrhotic, and cirrhotic/teprenone (100 mg/kg) pre-treated groups. Brain natriuretic peptide (BNP), tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), and monocyte chemo-attractant protein-1 (MCP-1), and alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were investigated in serum. The Hsp70, B-cell lymphoma 2 (Bcl-2), and B-cell lymphoma 2-associated X protein (Bax) expressions were quantified through real-time polymerase chain reaction (Real-time PCR).

KEY FINDINGS

The chronotropic responses were decreased significantly in cirrhotic and cirrhotic/teprenone groups. The QT interval and serum BNP, TNF-α, IL-6, ALT, AST, and MCP-1 levels were increased significantly in the cirrhotic and decreased significantly, except BNP, in the cirrhotic/teprenone group. The Hsp70 and Bax expressions increased significantly in cirrhotic and decreased significantly in the cirrhotic/teprenone group while the Bcl-2 decreased significantly in cirrhotic and increased significantly in the cirrhotic/teprenone group.

SIGNIFICANCE

Teprenone does not relieve the CI and BNP changes in CCM while other indices are treated. Given that CCM is a multifactorial disease and needs to target other genes and proteins concurrent with Hsp70 to relieve CCM.

Cirrhotic Cardiomyopathy

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.

Speckle Tracking Analysis Reveals Altered Left Atrial and Ventricular Myocardial Deformation in Patients with End-Stage Liver Disease

Background: Cardiac function can be influenced by liver cirrhosis and should be thoroughly evaluated before liver transplantation. We investigated left ventricular (LV) and, for the first time, left atrial (LA) strain and strain rate in end-stage liver cirrhosis patients of different etiologies. Methods: This retrospective, cross-sectional study evaluated left heart function in 80 cirrhosis patients and 30 controls using standardized echocardiographic techniques and speckle tracking technology (STE) analysis. Serum markers of liver function were used for correlation analysis. Results: While conventional parameters demonstrated no alteration in systolic function, speckle tracking analysis showed a significant increase in LV longitudinal strain throughout all cardiac layers, with significant correlation to model of end-stage liver disease (MELD) score. LA reservoir and conduit strain as well as LA strain rate in all phases were significantly reduced in end-stage liver disease (ESLD) patients compared to control. STE for the evaluation of LA phasic function seemed to be more sensitive than volumetric methods. Kaplan-Meier curves showed a trend towards reduced post-transplant survival in patients with a reduced LA reservoir and conduit strain. Conclusion: STE analysis detected increased LV and decreased LA deformation in cirrhosis patients, thus proving to be highly sensitive to cardiac changes and useful for more precise cardiac evaluation.

Mechanisms of kidney dysfunction in the cirrhotic patient: Non-hepatorenal acute-on-chronic kidney damage considerations

Renal dysfunction is a common finding in cirrhotic patients and has a great physiologic, and therefore, prognostic relevance. The combination of liver disease and renal dysfunction can occur as a result of systemic conditions that affect both the liver and the kidney, although primary disorders of the liver complicated by renal dysfunction are much more common. As most of the renal dysfunction scenarios in cirrhotic patients correspond to either prerenal azotemia or hepatorenal syndrome (HRS), physicians tend to conceive renal dysfunction in cirrhotic patients as mainly HRS. However, there are many systemic conditions that may cause both a "baseline" chronic kidney damage and a superimposed kidney dysfunction when this systemic condition worsens. The main aim of this article is to review some of the most important non prerenal non-HRS considerations regarding acute on chronic kidney dysfunction in cirrhotic patients, including renal manifestation of related to non-alcoholic steatohepatitis (NASH) viral hepatitis, the effect of cardiorenal syndrome in cirrhotics and corticosteroid-deficiency associated renal dysfunction.

Detection of calcified atheromas on panoramic radiographs of cirrhotic patients

BACKGROUND

The present study aimed to investigate the prevalence of calcified atheromas in carotid arteries (CACA) on panoramic radiographs of patients with liver cirrhosis (LC).

METHODS AND RESULTS

A case-control study of 67 individuals with LC (case group) and 67 healthy individuals (control group), matched by gender and age, was performed. In addition to demographic information, data on LC were also collected for the case group. Panoramic radiographs were evaluated by two previously calibrated examiners. The sample consisted predominantly of male individuals (n = 50; 74.62%), with mean age of 55 years old. In the case group, the mean value for the model of end-stage liver disease was 16, and the major aetiology of LC was alcoholism (n = 26; 38.8%). Thirteen (19.4%) LC patients had CACA, whereas only four (5.9%) healthy patients had this condition. LC patients are 3.72 times more likely to have CACA compared to healthy individuals (P = .02). The presence of nephropathies increases the risk of development of atheromas by 18.58 times in cirrhotic individuals (P = .04).

CONCLUSIONS

Cirrhotic patients are more likely to have CACA compared to healthy patients, and this risk increases significantly when kidney disease is involved.

Cirrhotic Cardiomyopathy - A Veiled Threat

Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.

Myocardial Dysfunction in Cirrhotic Cardiomyopathy is Associated with Alterations of Phospholamban Phosphorylation and IL-6 Levels

BACKGROUND

Decreased cardiac contractility has been observed in cirrhosis, but the mechanisms that initiate and maintain cardiac dysfunction are not entirely understood.

AIM OF THE STUDY

We test the hypothesis that cirrhotic cardiomyopathy is related to deterioration of myocardial contractility due to alterations in calcium-handling proteins expression. In addition, we evaluated whether cardiac pro-inflammatory cytokine levels are associated with this process.

METHODS

Cirrhosis was induced by thioacetamide (TAA, 100 mg/kg/i.p., twice weekly for eight weeks). The myocardial performance was evaluated in isolated left ventricle papillary muscles under basal conditions and after inotropic challenge. The cardiac calcium handling protein expression was detected by Western blotting. Cardiac TNF-α and IL-6 levels were measured by ELISA.

RESULTS

Thioacetamide induced liver cirrhosis, which was associated with cirrhotic cardiomyopathy characterized by in vivo left ventricular diastolic and systolic dysfunction as well as cardiac hypertrophy. In vitro baseline myocardial contractility was lower in cirrhosis. Also, myocardial responsiveness to post-rest contraction stimulus was declined. Protein expression for RYR2, SERCA2, NCX, pPBL Ser¹⁶ and L-type calcium channel was quantitatively unchanged; however, pPBL Thr¹⁷ was significantly lower while IL-6 was higher.

CONCLUSIONS

Our study demonstrates that cirrhotic cardiomyopathy is associated with decreased cardiac contractility with alteration of phospholamban phosphorylation in association with higher cardiac pro-inflammatory IL-6 levels. These findings provided molecular and functional insights about the effects of liver cirrhosis on cardiac function.

QTc prolongation in patients of cirrhosis and its relation with disease severity: An observational study from a rural teaching hospital

Introduction:

Cirrhotic cardiomyopathy is characterised by increased baseline cardiac output, systolic and diastolic dysfunction, diminished cardiovascular response to stressful stimuli and electrophysiological abnormalities in patients of cirrhosis in the absence of any underlying cardiac disease. QTc prolongation has been described as a common electrocardiographic abnormality in cirrhosis patients.

Aims and Objectives:

This study was done to evaluate the prevalence of QTc changes in patients of cirrhosis coming to a rural tertiary care centre and to analyse its correlation with disease severity.

Materials and Methods:

The present study was conducted on 100 patients suffering from cirrhosis of liver presented to the department of medicine. Around 100 age and sex-matched individuals were recruited as controls. The Child-Pugh score was used to determine the disease severity in cirrhosis patients. Standard 12-lead ECG was recorded in all cases and controls.

Results:

Prolongation of QTc interval on ECG was observed in the majority (80%) of cirrhosis patients and it was significantly higher as compared to the healthy controls (P <0.01). The prolongation of QTc was significantly associated with the duration of disease (P <0.05) and disease severity as measured by the Child-Pugh score (P <0.01).

Conclusion:

QTc prolongation on ECG may be an early marker of cardiac involvement in patients of cirrhosis and is significantly associated with disease severity.

Impact of Intraoperative Norepinephrine Support on Living Donor Liver Transplantation Outcomes: A Retrospective Cohort Study of 430 Children

Norepinephrine (NE) is often administered during the perioperative period of liver transplantation to address hemodynamic instability and to improve organ perfusion and oxygen supply. However, its role and safety profile have yet to be evaluated in pediatric living donor liver transplantation (LDLT). We hypothesized that intraoperative NE infusion might affect pediatric LDLT outcomes. A retrospective study of 430 pediatric patients (median [interquartile range] age, 7 [6.10] months; 189 [43.9%] female) receiving LDLT between 2014 and 2016 at Renji Hospital was conducted. We evaluated patient survival among recipients who received intraoperative NE infusion (NE group, 85 recipients) and those that did not (non-NE group, 345 recipients). The number of children aged over 24 months and weighing more than 10 kg in NE group was more than that in non-NE group. And children in NE group had longer operative time, longer anhepatic phase time and more fluid infusion. After multivariate regression analysis and propensity score regression adjusting for confounding factors to determine the influence of intraoperative NE infusion on patient survival, the NE group had a 169% more probability of dying. Although there was no difference in mean arterial pressure changes relative to the baseline between the two groups, we did observe increased heart rates in NE group compared with those of the non-NE group at anhepatic phase (P=0.025), neohepatic phase (P=0.012) and operation end phase (P=0.017) of the operation. In conclusion, intraoperative NE infusion was associated with a poorer prognosis for pediatric LDLT recipients. Therefore, we recommend the application of NE during pediatric LDLT should be carefully re-considered.

Electrocardiographic Changes in Liver Cirrhosis-Clues for Cirrhotic Cardiomyopathy

Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.