Global Longitudinal Strain at Rest as an Independent Predictor of Mortality in Liver Transplant Candidates: A Retrospective Clinical Study

Abstract

Speckle tracking echocardiography enables the detection of subclinical left ventricular dysfunction at rest in many heart diseases and potentially in severe liver diseases. It could also possibly serve as a predictor for survival. In this study, 117 patients evaluated for liver transplantation in a single center between May 2010 and April 2016 with normal left ventricular ejection fraction were included according to clinical characteristics of their liver disease: (1) compensated (n = 29), (2) clinically significant portal hypertension (n = 49), and (3) decompensated (n = 39). Standard echocardiography and speckle tracking echocardiography were performed at rest and during dobutamine stress. Follow-up amounted to three years to evaluate survival and major cardiac events. Altogether 67% (78/117) of the patients were transplanted and 32% (31/96 patients) died during the three-year follow-up period. Global longitudinal strain (GLS) at rest was significantly increased (became more negative) with the severity of liver disease (p < 0.001), but reached comparable values in all groups during peak stress. Low (less negative) GLS values at rest (male: >-17/female: >-18%) could predict patient survival in a multivariate Cox regression analysis (p = 0.002). GLS proved valuable in identifying transplant candidates with latent systolic dysfunction.

Keywords: cardiac systolic function; cirrhotic cardiomyopathy; dobutamine stress test; echocardiography; outcome; strain analysis.

Figure 1

Overview of the inclusion and exclusion criteria.

Figure 2

Effect of dobutamine stress echocardiography (DSE) on left ventricular function related to the severity of liver disease. The values at ‘base’ were recorded at rest before DSE, at ‘low’ with a dobutamine rate of 10 µg/kg BW/min, at ‘peak’ with the maximum dobutamine rate and at ‘post’ after stopping dobutamine and returning to baseline heart rates (mean +/− SD). The following parameters of left ventricular function are shown (a) global longitudinal strain (GLS), (b) left ventricular ejection fraction (LVEF), (c) end-diastolic volume index (EDVi) and (d) stroke volume index (SVi) (# p ≤ 0.05 between groups and * p < 0.05 vs. cALD at time point).

Figure 3

Kaplan-Meier survival curves: survival probability was displayed according to (a) liver disease groups, (b) liver transplantation and (c) global longitudinal strain (GLS) categories.