Post-liver transplantation myocardial dysfunction

Abstract

Patients with end-stage liver disease usually show a hyperdynamic circulatory state. It has previously been reported that patients who develop myocardial depression in the early post-liver transplantation period are more prone to organ failure and death. We reviewed the records of 754 adult patients undergoing liver transplantation at our institution and identified 7 patients who initially showed hyperdynamic circulation, but then developed reversible dilated cardiomyopathy in the early posttransplantation period. All identifiable causes of cardiac dysfunction, such as myocardial ischemia, thyroid dysfunction, and electrolyte imbalances, were excluded. Left ventricular ejection fraction decreased from a preoperative median baseline of 60% to 20% (P ‫؍‬ .02), with four-chamber dilatation on echocardiogram. All these patients required supportive care, including mechanical ventilation, afterload reduction, inotropic support, and monitoring in the intensive care unit. Cardiac function subsequently improved in all patients, with ejection fraction increasing to a median of 50%. All patients were discharged from the hospital. At a median follow-up of 15 months, there was no recurrence of heart failure. The increased peripheral resistance seen after successful liver transplantation may be an important causative factor. Copyright 1998 by the American Association for the Study of Liver Diseases H yperdynamic circulation has been repeatedly documented in patients with liver disease since the first description of the hyperdynamic circulatory state by Kowalski and Abelman in 1953. 1 Even those patients who were not previously hyperdynamic can respond to recirculation at the time of orthotopic liver transplantation (OLT) by developing a hyperdynamic circulatory state. 2 This hyperdynamic circulatory state usually resolves in the weeks after transplantation, 3,4 although it can sometimes persist even after successful liver transplantation. 5 We describe a small subset of post-OLT patients who showed an initial hyperdynamic circulatory state, followed by a period of markedly reduced cardiac function associated with cardiac dilatation and associated clinical heart failure. This document is the first to characterize this syndrome of reversible, dilated cardiomyopathy after OLT. Materials and MethodsWe reviewed a summary of the medical records of 754 adults (Ͼ18 years of age) undergoing OLT at the Mayo Clinic (Rochester, MN) from March 1985 through December 1996. The medical records of patients with chest radiograph evidence of pulmonary edema were carefully reviewed to identify a subset of patients with myocardial dysfunction, all of whom had echocardiographic evidence of a dilated cardiomyopathy post-OLT. We excluded patients with myocardial infarction at the time of congestive heart failure. Myocardial infarction was defined as elevation of cardiac enzyme levels with or without electrocardiographic changes. We also excluded patients who had intraoperative cardiac complications such as myocardial infarction, severe persistent hy...

Cirrhotic cardiomyopathy

“…Sampathkumar and colleagues [88] reported severe myocardial dysfunction occurring in 1% of patients after liver transplantation. During reperfusion, the return of a significant volume to the heart can unmask any diastolic dysfunction.…”

Hepatorenal Syndrome

“…In the absence of increased metabolic demand, this cardiac dysfunction remains clinically silent masked by the afterload reduction that is observed in cirrhosis. Clinical experience suggests that cardiac reserve may be diminished and acute heart failure may manifest in otherwise stable patients after TIPS or liver transplantation (46,47). Cardiac dysfunction, along with its contribution to HRS, clearly needs further studies to determine whether it is involved directly in the pathogenesis of HRS or merely serves as a marker of an alternative factor that is involved in HRS development.…”

Non invasive continuous hemodynamic evaluation of cirrhotic patients after postural challenge

“…Recent studies documented the clinical impact of cardiovascular abnormalities in cirrhotic patients [17] , especially when submitted to surgical procedures, such as TIPS insertion [6,7,18] and liver transplantation [19] . Sampathkumar and colleagues [19] reported severe myocardial dysfunction in 1% of patients after liver transplantation, since during reperfusion, the return of a significant volume to the heart can unmask any diastolic dysfunction.…”

“…Sampathkumar and colleagues [19] reported severe myocardial dysfunction in 1% of patients after liver transplantation, since during reperfusion, the return of a significant volume to the heart can unmask any diastolic dysfunction. When followed long-term for over 1 year, there is complete reversal of cardiac changes in post transplant patients.…”