Current Concepts of Cirrhotic Cardiomyopathy

Abstract

Cirrhotic cardiomyopathy (CCM) connotes systolic and/or diastolic dysfunction in patients with end-stage liver disease in the absence of prior heart disease. Its prevalence is variable across different studies but recent data suggest that CCM may affect up to one third of liver transplant candidates. The etiology of CCM is multifactorial. CCM defining features were recently revised to improve the diagnostic and prognostic yield of CCM criteria and inform candidate selection for liver transplantation. CCM appears to increase the risk for unfavorable outcomes pre- and post-transplant. Close clinical and echocardiographic follow-up of patients with CCM may mitigate adverse cardiac outcomes.

Keywords: Cardiovascular events; Cirrhotic cardiomyopathy; Diastolic dysfunction; Echocardiogram; Heart disease; Heart failure; Liver transplantation; Transjugular intrahepatic portosystemic shunt.

Figure 1.

Overview of the role of cirrhosis physiology in the development of cirrhotic cardiomyopathy

Figure 2.

The Revised Criteria for Cirrhotic Cardiomyopathy Abbreviations: LVEF, left ventricular ejection fraction; GLS, global longitudinal strain; E/A, early to late diastolic transmitral flow velocity; e, early diastolic mitral annular tissue velocity; LAVI, left atrial volume index, TR, tricuspid regurgitation.

* GLS is a negative value reflecting myocardial fiber shortening during systole. To avoid confusion, using the absolute value is recommended to describe changes in GLS.

**Presence of only 2 abnormalities suggests diastolic dysfunction of indeterminate grade. Further evaluation is needed using E/A ratio change during Valsalva, pulmonary vein velocity, GLS, left atrial strain, and isovolumetric relaxation time.

*** This criterion is only applicable in the absence of primary pulmonary hypertension or portopulmonary hypertension.

Figure 3.

Topics and questions for future research about Cirrhotic Cardiomyopathy Abbreviations: CCM, cirrhotic cardiomyopathy; HRS, hepatorenal syndrome; TIPS, transjugular intrahepatic portosystemic shunt. *Examples: abnormal chronotropic or inotropic response, electrocardiographic changes, electromechanical uncoupling, myocardial mass change, changes on cardiac magnetic resonance imaging, and serum biomarkers.