Introduction

Cirrhotic cardiomyopathy (CCM), cardiac dysfunction in liver cirrhosis of any aetiology in the absence of a primary cardiac cause predisposes to morbidity and mortality before and after Liver Transplantation (LT). Global longitudinal strain (GLS) measurement is included in the updated CCM criteria to detect subclinical myocardial dysfunction. Myocardial work (MW) is a novel echocardiographic measure, combining GLS with simultaneous blood pressure measurements has been found to correlate well with invasively measured global myocardial function. MW is not reported in cirrhosis and CCM.

Aims & Methods

The primary aim was to evaluate global cardiac function in decompensated cirrhosis using advanced echocardiographic parameters at rest and with dobutamine stress echo (DSE), and to study their association with development of a composite clinical outcome including acute kidney injury/hepatorenal syndrome, refractory ascites, cardiac failure and death over the subsequent 12 months. The secondary aims were to report the prevalence of CCM and to assess its association with the study outcome; to assess the diagnostic utility of cardiac biomarkers (NT-pro-BNP and cardiac troponin T) in CCM, and re-assess cardiac function at 12 months of successful LT.
Prospective study of cirrhotic patients with ascites or undergoing LT assessment from January 2021 to August 2022, with 12-month follow-up. After a written consent, clinical profile, Model for End-stage Liver Disease sodium (MELD Na) score, and cardiac biomarkers were evaluated. Transthoracic echo and DSE measured GLS and calculated MW (GWI (global work index), GCW (global constructive work), GWE (global work efficiency) and GWW (global wasted work). Statistical analysis was conducted using SPSS IBM Statistics version 29. Difference in estimated marginal mean difference in MW between baseline and DSE were obtained using repeated measures of ANOVA. Univariate analysis of clinical, echocardiographic and demographic features on the study outcome was assessed using either independent t-test or chi-squared test as appropriate. Significant predictors from the univariate analysis (p<0.05) were included in multivariate Cox regression analysis.

Results

96 patients with mean±SD age 56±11 years; (58% male; 59% alcohol misuse) were studied. The mean±SD MELD Na was 17±11. 16 patients underwent LT; 53 developed the composite clinical outcome. MELD Na, troponin, LVEF, rest and peak GLS, rest and peak GWI, peak GWE and E/e’ were significantly higher in patients meeting study outcome in univariate analysis. MELD Na and E/e’ were positively associated in multivariate analysis with HR (95%CI)=1.075:1.018–1.135; p=0.009 and HR=1.179; 1.037–1.340; p=0.012 respectively. There was a significant decrease in GLS and MW on DSE. There was a significant correlation between MELD Na and rest GLS (r=0.30, p<0.001). Based on new CCM criteria, systolic dysfunction was detected in 17% and diastolic dysfunction in 13% and CCM in 27%. There was no association between CCM and the composite study outcome. Median (IQR) troponin was 13.5 ng/ml (7.0–24.0) and BNP was 189 (pg/ml) (53.0–374.0). There was no association between these biomarkers and CCM. Ten patients evaluated post LT, demonstrated significant improvements in GLS, MW and LVEF.

Conclusion

In our patients with advanced cirrhosis, the study revealed increased myocardial work without any augmentation on DSE. CCM observed in a quarter of patients, had no impact on clinical course before/ after LT. Further studies are warranted to validate the updated CCM criteria and improve its clinical utility.

Disclosure

no cnfict t if interest