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.

Update on cirrhotic cardiomyopathy: from etiopathogenesis to treatment

“…Further studies have also investigated the relationship between GLS and the severity of cirrhosis according to the model for end-stage liver disease (MELD) and the Child-Pugh scores, and whether GLS is related to prognosis [ 62 ]. Mechelink et al showed that patients with advanced cirrhosis, including significant portal hypertension or decompensated cirrhosis, had a higher resting GLS.…”

“…Mechelink et al showed that patients with advanced cirrhosis, including significant portal hypertension or decompensated cirrhosis, had a higher resting GLS. However, other studies report contradictory findings: for instance, more advanced cirrhosis, as defined by Child-Pugh or MELD, was not necessarily associated with a significantly higher GLS [ 62 ]. In the study by Mechelink et al , patients with a higher GLS were characterized by a lower contractile reserve, as shown by a dobutamine stress test, than patients with an initially lower GLS.…”

“…Since GLS is a parameter influenced by both contractility and preload, a high GLS at baseline highlighted the high output state and hemodynamic stress associated with advanced cirrhosis. Given that patients with advanced cirrhosis are already likely to have a higher mortality rate, a low GLS was considered an independent predictor of mortality [ 62 , 63 ]. On the other hand, in a study by Skouloudi et al , there was no difference in mortality in cirrhotic patients with a GLS lower or higher than the absolute mean of 22.7% [ 46 ].…”

“…The fact that the stress test has lost significance according to the new criteria seems unfortunate, as an insufficient increase in cardiac output is ultimately a key feature of CCM. Nevertheless, stress echocardiography is an important tool, not essential for diagnosis, but for the further assessment, preprocedural evaluation and risk stratification of patients with CCM [ 62 ].…”

“…Thus, the parameters for TDI appear to be more specific in the diagnosis of diastolic dysfunction, although the CCC criteria make the assessment of diastolic function more complex. It should be stressed that the CCC criteria practically exclude patients with grade I diastolic dysfunction, and that in one group of patients, diastolic function is defined as indeterminate, which complicates the classification of these patients [ 62 ]. However, studies have shown that abnormalities in TDI parameters of diastolic dysfunction in CCM are associated with disease progression after transplantation.…”