Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Table 1 Cirrhotic cardiomyopathy and liver transplantation

Key points
CCM is a latent cardiac dysfunction that is independent of aetiology and may be unmasked during periods of increased cardiovascular demand
It is characterised by systolic incompetence to stress, diastolic dysfunction and electrophysiological abnormalities
The persistent over-activation of the SNS in cirrhosis leads to down-regulation and dysfunction of the β-adrenergic receptor, a key pathological feature in CCM
Clinical implications include an increased risk of hepatorenal syndrome, cardiac failure following TIPS insertion and increased risk of arrhythmias during acute gastrointestinal bleeding
Diagnosis can be made using a combination of echocardiography (resting and stress), tissue Doppler imaging, cardiac MRI, 12 lead ECG and measurement of biomarkers
Cardiac status should be re-evaluated regularly until liver transplant
Peri-operative management at transplantation should involve careful choice of graft and minimisation of large fluctuations in preload and afterload
Long term there is a resolution of the abnormalities in CCM

CCM: Cirrhotic cardiomyopathy; SNS: Sympathetic nervous system; TIPS: Transjugular intrahepatic portosystemic shunts; ECG: Electrocardiogram.

Table 2 2005 World Congress of Gastroenterology diagnostic and supportive criteria for cirrhotic cardiomyopathy[1]

A working definition of cirrhotic cardiomyopathy

A cardiac dysfunction in patients with cirrhosis characterised byimpaired contractile responsiveness to stress and/or altered diastolicrelaxation with electrophysiological abnormalities in the absence ofother known cardiac disease

Diagnostic criteria

Systolic dysfunction

Blunted increase in cardiac output on exercise, volume challenge orpharmacological stimuli

Resting LVEF < 55%

Diastolic dysfunction

E/A ratio < 1 (age-corrected)

Prolonged deceleration time (> 200 ms)

Prolonged isovolumetric relaxation time (> 80 ms)

Supportive criteria

Electrophysiological abnormalities

Abnormal chronotropic response

Electromechanical uncoupling

Prolonged QTc interval

Enlarged left atrium

Increased myocardial mass

Increased BNP (brain natriuretic peptide) and pro-BNP

Increased troponinI

BNP: B-type natriuretic peptide; LVEF: Left ventricular ejection fraction.