An update on cirrhotic cardiomyopathy

ABSTRACT

Introduction: Cirrhosis with portal hypertension and related complications are associated with a high mortality. Excess of circulating vasodilators and cardiodepressive substances lead to a hyperdynamic circulation with changed myocardial structure and function. The entity cirrhotic cardiomyopathy seems to be involved in different aspects of hepatic decompensation, which focuses on new targets of treatment.

Areas covered: This review deals with contemporary aspects of cirrhotic cardiomyopathy, and the literature search was undertaken by PubMed with ‘cirrhotic’ and ‘cardiomyopathies’ as MeSH Terms. Cirrhotic cardiomyopathy is defined as the presence of systolic and diastolic dysfunction and electrophysiological abnormalities. The diagnosis is based on contemporary Doppler/Echocardiography measurements or quantitative magnetic resonance imaging. Cirrhotic cardiomyopathy is independent of the etiology of the liver disease but related to severity and survival.

Expert commentary: The outcome of invasive procedures and liver transplantation is influenced by the presence of cardiac dysfunction. Therefore, a cautious cardiac evaluation should be included in the patient evaluation prior to liver transplantation. Liver transplantation ameliorates most of the abnormalities seen in cirrhotic cardiomyopathy, but no specific treatment can yet be recommended.

KEYWORDS:

• Cirrhotic cardiomyopathy
• heart failure
• cirrhosis
• portal hypertension
• cardiovascular dysfunction
• arterial vasodilatation
• hyperdynamic circulation
• systolic dysfunction
• diastolic dysfunction
• QT-interval
• liver transplantation

Article highlights box

• Hepatic failure and portal hypertension lead to arterial vasodilatation with an excess of circulating vasodilators and cardiodepressive substances.

• Among the hemodynamic consequences are development of a hyperdynamic circulation with increased cardiac output, heart rate, and impaired myocardial structure and function.

• The cirrhotic heart displays myocardial hypertrophy, fibrosis and increased left atrial volume.

• The entity cirrhotic cardiomyopathy has been defined as the presence of systolic and diastolic dysfunction and electrophysiological abnormalities.

• The diagnosis should be made based on dynamic stress testing with physical or pharmacological exercise or contemporary Doppler/Echocardiography measurements with an assessment of myocardial strain imaging. Quantitative MRI represents a new appealing diagnostic approach.

• Cirrhotic cardiomyopathy is independent of the etiology of the liver disease but related to severity and survival. In patients with advanced cirrhosis low cardiac output is associated with the development of hepatorenal dysfunction.

• Outcome after TIPS and liver transplantation and post-transplant development of heart failure depend on the presence of in particular diastolic dysfunction.

• A cautious cardiovascular evaluation should be included in the wrap-up prior to liver transplantation.

• Liver transplantation ameliorates most of the abnormalities seen in cirrhotic cardiomyopathy. No specific treatment can be recommended but the translation of experimental principles into clinical practice is anticipated.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The work was supported by grants from the Novo Nordisk Foundation (NNF11OC1014467), Ferring Pharmaceuticals, and the Hvidovre Hospital Research Foundation.