Cirrhotic Cardiomyopathy: The Interplay Between Liver and Heart

Abstract

Cardiac vascular dysfunction was described years ago in alcohol-associated liver cirrhosis and recently became known as cirrhotic cardiomyopathy (CCM) in 2005. Cirrhotic cardiomyopathy is a specific cardiac dysfunction estimated to be prevalent in half of the liver cirrhosis patient population; it comprises a triad of impaired myocardial contractile responses to stress (systolic dysfunction), inadequate ventricular relaxation, and electrophysiological abnormalities. This review describes the various pathophysiological mechanisms connecting liver cirrhosis to the alterations seen in CCM and briefly mentions the role of the cardiovascular system in connecting the pathophysiology of hepatorenal syndrome (HRS). Insertion of the transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation exacerbates the underlying cardiac dysfunction leading to signs and symptoms of heart failure. This article also focuses on the clinical importance of diagnosing CCM and the limitations existing around traditional diagnostic criteria based on transmitral flow parameters. It highlights newer parameters proposed by the Cirrhotic Cardiomyopathy Consortium to obtain a diagnosis of CCM. Liver transplantation is the only treatment available to cure CCM.

Keywords: cardiac cirrhosis; cardio hepatorenal syndrome; cirrhotic cardiomyopathy; cirrhotic cardiomyopathy consortium criteria; diastolic dysfunction; myocardial strain imaging; systolic dysfunction.

Figure 1. Pathogenic events following liver cirrhosis leading up to CCM

CCM: Cirrhotic cardiomyopathy, NO: Nitric oxide, SNS: Sympathetic nervous system, RAAS: Renin-angiotensin-aldosterone system, ADH: Antidiuretic hormone, SVR: Systemic vascular resistance, CO: Cardiac output, HR: Heart rate, SV: Stroke volume, BP: Blood pressure Image credits: Figure created by author Revanth Kalluru

Figure 2. Diagnostic and defining criteria of CCM

CCM: Cirrhotic cardiomyopathy, LVEF: Left ventricular ejection fraction, E: Early ventricular filling velocity, A: Late/atrial ventricular filling velocity, IVRT: Isovolumetric relaxation time, QTc: Corrected QT interval, GLS: Global longitudinal strain, e’:  End diastolic mitral annular velocity Image credits: Figure created by author Revanth Kalluru