Cardiac and vascular changes in cirrhosis: Pathogenic mechanisms

Abstract

Cardiovascular abnormalities accompany both portal hypertension and cirrhosis. These consist of hyperdynamic circulation, defined as reduced mean arterial pressure and systemic vascular resistance, and increased cardiac output. Despite the baseline increased cardiac output, ventricular inotropic and chronotropic responses to stimuli are blunted, a condition known as cirrhotic cardiomyopathy. Both conditions may play an initiating or aggravating pathogenic role in many of the complications of liver failure or portal hypertension including ascites, variceal bleeding, hepatorenal syndrome and increased postoperative mortality after major surgery or liver transplantation. This review briefly examines the major mechanisms that may underlie these cardiovascular abnormalities, concentrating on nitric oxide, endogenous cannabinoids, central neural activation and adrenergic receptor changes. Future work should address the complex interrelationships between these systems.

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

“…Replenishment for third-space loss should be performed using not Ringer's solution but bicarbonated Ringer's solution [57][58][59] if the electrolyte composition is similar to that of the extracellular fluid and if the thirdspace loss is quantitatively large. Careless management techniques, such as rapid increases or decreases of transfusions and medications, are detrimental [60,61] . Effects of increases or decreases of transfusions are usually reflected on a day-to-day basis because of the peculiar cirrhotic hemodynamics [55,60,61] , and a roller-coaster management technique that repeatedly changes within a single day will trigger poor clinical courses with unexpected complications [60,61] .…”

“…Careless management techniques, such as rapid increases or decreases of transfusions and medications, are detrimental [60,61] . Effects of increases or decreases of transfusions are usually reflected on a day-to-day basis because of the peculiar cirrhotic hemodynamics [55,60,61] , and a roller-coaster management technique that repeatedly changes within a single day will trigger poor clinical courses with unexpected complications [60,61] . All transfusion management plans should be handled with great caution, and transplant physicians should very carefully evaluate the effects of increases or decreases of transfusions [60][61][62] .…”

“…Effects of increases or decreases of transfusions are usually reflected on a day-to-day basis because of the peculiar cirrhotic hemodynamics [55,60,61] , and a roller-coaster management technique that repeatedly changes within a single day will trigger poor clinical courses with unexpected complications [60,61] . All transfusion management plans should be handled with great caution, and transplant physicians should very carefully evaluate the effects of increases or decreases of transfusions [60][61][62] . A response time lag due to endothelial injury and permeant breakdown should be considered in LC recipients with long-term PH [63][64][65] .…”

“…Adequate hydration is also required; dehydration should be avoided because of these patients' peculiar hemodynamics. Even temporal dehydration causes unexpected thrombosis, renal failure, and impaired drug metabolism [60][61][62] . Plans to stay within stable systemic hemodynamics (e.g., noradrenaline to maintain CO and well-hydration with human atrial natriuretic peptide) should be considered.…”

Perioperative Monitoring in Liver Transplant Patients

“…Due to this relative hypovolemia and major fluid shifts which occur during surgery, there is a need for a reliable hemodynamic monitoring tool for fluid management, so as to maintain the delicate balance between optimizing preload and avoiding pulmonary edema. 3 Standard hemodynamic monitoring used routinely during adult LT includes continuous 5 lead ECG, invasive arterial pressure and cardiac output (CO) monitoring. Often both the radial arteries or a radial and a femoral artery are cannulated due to the need for frequent blood sampling and to enable continuous invasive blood pressure monitoring during the long surgery.…”