Diastolic dysfunction is a predictor of poor outcomes in patients with cirrhosis, portal hypertension, and a normal creatinine

Abstract

We investigated left ventricular diastolic dysfunction (LVDD) and its relationship with circulatory function and prognosis in cirrhosis with portal hypertension and normal creatinine. Conventional and tissue Doppler (TDI) echocardiography, systemic and hepatic hemodynamics, and the activity of endogenous vasoactive systems (AEVS) were measured prospectively in 80 patients. Plasma renin activity (PRA; >4 ng/mL/hour) was used as a surrogate of effective arterial blood volume. Patients were followed up for 12 months. Thirty-seven patients had LVDD (19 with grade 1 and 18 with grade 2). Left ventricular hypertrophy, left atrial volume, AEVS, and natriuretic peptide levels were significantly greater in patients with LVDD than without LVDD. Patients with grade 2 LVDD, compared to grade 1 LVDD and without LVDD, had significantly lower mean arterial pressure and higher Model for End-Stage Liver Disease (MELD) score, E-wave transmitral/early diastolic mitral annular velocity (E/e' ratio), cardiopulmonary pressures, PRA, and natriuretic peptide levels. Systolic and cardiac chronotropic function were significantly lower in patients with grade 2 LVDD than without LVDD. LVDD was more frequent in patients with ascites and increased PRA than patients without ascites or with ascites but normal PRA. Fourteen patients with LVDD developed hepatorenal syndrome (HRS) type 1 on follow-up. Survival was different according to degree of LVDD (without LVDD: 95%; grade 1 LVDD: 79%; grade 2 LVDD: 39%; P < 0.001). Independent predictive factors of mortality were MELD score and E/e' ratio. Conclusion: LVDD occurs simultaneously with other changes in cardiac structure and function and is associated with an impairment of effective arterial blood volume. LVDD is a sensitive marker of advanced cirrhosis, type 1 HRS development, and mortality. (HEPATOLOGY 2013;58:1732-1741 C irrhosis is associated with a specific subclinical cardiomyopathy 1-4 characterized by diminished systolic responsiveness to stress stimuli, 5,6 impaired diastolic relaxation, 7,8 electrophysiological abnormalities, 9 and enlargement and hypertrophy of cardiac chambers, 10,11 all in the absence of known cardiac disease. However, evidence suggests that patients with cirrhosis display primarily left ventricular diastolic dysfunction (LVDD) with normal systolic function at rest. 7Abbreviations: 2D, two-dimensional; A, atrial wave-filling peak; ALDO, plasma concentrations of aldosterone; ANF, atrial natriuretic factor; ASE, the American Society of Echocardiography; AUC, area under the curve; BNP, brain natriuretic peptide; CI, confidence interval; CO, cardiac output; DT, deceleration time; E, E-wave transmitral peak early filling; e 0 , early diastolic mitral annular velocity; E/A, early diastolic mitral inflow velocity/late diastolic; E/e 0 ratio, E-wave transmitral/early diastolic mitral annular velocity; FHVP, free hepatic venous

Assessment of diastolic function in the management of patients with cirrhosis

“…As in the present study by Karagiannakis et al, several studies have reported a direct relation to prognosis, whereas other studies have failed to do so [6,8,14]. In a recent study by Ruiz-del-Arbol et al [8], the authors reported a direct relationship between variables obtained from tissue Doppler imaging (E/e 0 ) ratio and prognosis. In patients undergoing invasive procedures such as insertion of a transjugular intrahepatic porto systemic shunt (TIPS), the presence of diastolic dysfunction has been shown to predict survival [9].…”

“…This condition has been termed cirrhotic cardiomyopathy, which designates a cardiac dysfunction that includes impaired cardiac contractility with systolic and diastolic dysfunction and electromechanical abnormalities in the absence of other known causes of cardiac disease [4]. Cirrhotic cardiomyopathy can be demasked by physical or pharmacological stress, which may reveal in particular a systolic dysfunction, which seems to contribute to several cirrhotic complications such as the formation of ascites [5,6] and the development of hepatic nephropathy [7,8]. Additionally, cirrhotic cardiomyopathy seems associated with the development of heart failure in relation to invasive procedures such as shunt insertion and liver transplantation [9,10].…”

“…The prevalence of diastolic dysfunction among patients with cirrhosis varies according to the type of population and the severity of the disease, but there seems to be no relationship to etiology of cirrhosis. Different prevalences have been published ranging from 15 % to as high as 67 % [5,6,8,[14][15][16]. A considerable number of studies have reported a direct relationship between the severity of diastolic dysfunction and severity of the liver disease, as reflected by the MELD-score, presence of ascites, and Child-Turcotte score, whereas some studies have been unable to detect a relationship with the degree of liver dysfunction [6,8].…”

“…Different prevalences have been published ranging from 15 % to as high as 67 % [5,6,8,[14][15][16]. A considerable number of studies have reported a direct relationship between the severity of diastolic dysfunction and severity of the liver disease, as reflected by the MELD-score, presence of ascites, and Child-Turcotte score, whereas some studies have been unable to detect a relationship with the degree of liver dysfunction [6,8]. As in the present study by Karagiannakis et al, several studies have reported a direct relation to prognosis, whereas other studies have failed to do so [6,8,14].…”

“…A considerable number of studies have reported a direct relationship between the severity of diastolic dysfunction and severity of the liver disease, as reflected by the MELD-score, presence of ascites, and Child-Turcotte score, whereas some studies have been unable to detect a relationship with the degree of liver dysfunction [6,8]. As in the present study by Karagiannakis et al, several studies have reported a direct relation to prognosis, whereas other studies have failed to do so [6,8,14]. In a recent study by Ruiz-del-Arbol et al [8], the authors reported a direct relationship between variables obtained from tissue Doppler imaging (E/e 0 ) ratio and prognosis.…”