The Contemporary Role of Speckle Tracking Echocardiography in Cirrhotic Cardiomyopathy

Abstract

Cirrhotic cardiomyopathy (CCM) is characterized by elevated cardiac output at rest, an inability to further increase contractility under stress, and diastolic dysfunction. The diagnosis of CCM is crucial as it can lead to complications during liver transplantation. However, its recognition poses challenges with conventional echocardiography techniques. Speckle tracking echocardiography (STE), particularly global longitudinal strain (GLS), is a novel index that enhances the diagnostic efficacy of echocardiography for both ischemic and non-ischemic cardiomyopathies. GLS proves more sensitive in identifying early systolic dysfunction and is also influenced by advanced diastolic dysfunction. Consequently, there is an expanding scope for GLS utilization in cirrhotic cases, with newly updated diagnostic criteria for CCM incorporating GLS. Specifically, systolic dysfunction is now defined as either a left ventricular ejection fraction below 50% or an absolute GLS below 18%. However, conflicting data on GLS alterations in liver cirrhosis patients persist, as many individuals with advanced disease and a poor prognosis exhibit a hyperdynamic state with preserved or increased GLS. Consequently, the presence of CCM, according to the updated criteria, does not exhibit a significant association-in the majority of studies-with the severity of liver disease and prognosis. Furthermore, information on other indices measured with STE, such as left atrial and right ventricular strain, is promising but currently limited. This review aims to offer a critical assessment of the existing evidence concerning the application of STE in patients with liver cirrhosis.

Keywords: cirrhotic cardiomyopathy; global longitudinal strain; liver cirrhosis; speckle tracking echocardiography.

Figure 1

Pathophysiological mechanisms implicated in CCM. Several molecules produced by the cirrhotic liver or by the induced inflammation result in vasodilation and desensitization of b-adrenergic receptors. These changes result in RAA activation and adrenergic stimulation, which are responsible for volume overload, eccentric cardiac hypertrophy, DD, and a blunted response to stress. The resulting cardiac dysfunction can, in turn, induce further activation of RAAS and SNS. Parts of the figure were drawn using pictures from Servier Medical Art (https://creativecommons.org/licenses/by/3.0/, 21 November 2023). CO: carbon monoxide; IL-6: interleukin-6; NO: nitric oxide; RAAS: renin-angiotensin-aldosterone system; SNS: sympathetic nervous system; VEGF: vascular endothelial growth factor.