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Cardiac involvement in patients with end-stage liver disease, beyond the hepatopulmonary syndrome
Afectación cardiaca en pacientes con enfermedad hepática avanzada, más allá del síndrome hepatopulmonar
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Colunga Blanco, C. Corros Vicente, A. García Campos, J.M. de la Hera Galarza" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Colunga Blanco" "email" => array:1 [ 0 => "santicolunga@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Corros Vicente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "García Campos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "de la Hera Galarza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Afectación cardiaca en pacientes con enfermedad hepática avanzada, más allá del síndrome hepatopulmonar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The intimate relationship between the heart and liver has long been known. Patients with acute and chronic heart failure develop liver symptoms, and cardiac cirrhosis and congestive hepatopathy encompass a spectrum of liver disorders that occur in the context of right-sided heart failure. The involvement of the cardiovascular system in patients with end-stage liver disease (ESLD) is also known and can be considered in various scenarios in adults who are candidates for liver transplantation.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> Hepatopulmonary syndrome (HS) is a relatively common pulmonary vascular complication of cirrhosis and portal hypertension. The diagnosis of HS requires the presence of the triad of ESLD, diffuse intrapulmonary vasodilation and arterial hypoxemia due to abnormal gas exchange (defined by an increase in the alveolar-arterial oxygen gradient of 15<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3–5</span></a> The presence of this syndrome has been reported in 5–30% of patients with ESLD, and the cardiopulmonary prognosis of these patients (with a mortality rate of 41% in 2 years) is even poorer than that of the general population with ESLD. Medical therapy has generally been ineffective, and liver transplantation is currently the only effective treatment for HS that will result in significant improvement in gas exchange after surgery and normalization of arterial oxygen levels in more than 85% of cases.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3,5</span></a> Although liver transplantation is the only definitive treatment, the presence of HS is associated with reduced survival and a poorer prognosis even in cases with liver transplantation.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of coronary artery disease in these patients is controversial; however, recent studies have suggested that this could occur more often than previously thought, which could indicate an additional risk to the presence of HS.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,6</span></a> A careful evaluation and selection of candidates for liver transplantation should therefore be conducted. The preoperative study of the heart's condition is of crucial importance in risk stratification and management. Due to their reduced physical activity, liver disease-related symptoms and concurrent morbidity, patients with ESLD can present symptoms that mask heart disease.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3,5,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of our study was to assess the presence of cardiac impairment and the prevalence of HS in patients with ESLD and its resolution and outcome after liver transplantation. Between 2010 and 2014, we selected 268 patients with a mean age of 59 years (SD, 8 years) with chronic liver disease who met the study criteria. All patients underwent a clinical examination, laboratory analysis and transthoracic echocardiography with an injection of agitated saline.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Alcohol abuse was the main cause of the liver disease (52% of cases), followed by hepatitis C virus infection (26%). Seventy-seven percent of the patients were men. In terms of cardiovascular risk factors, 27% of the patients had hypertension, 33% had diabetes mellitus, 7% had dyslipidemia, and 53% used tobacco. Ten percent of the patients presented renal failure, 7% had peripheral vascular disease, and 5% had chronic obstructive pulmonary disease. Five percent of the patients had a previous history of coronary artery disease. We performed ischemia detection tests on 14 patients and coronary angiography on 58 (22%), observing significant coronary artery disease in 34% of these patients. The right coronary artery was the most commonly affected vessel (59%). We performed coronary revascularization in 2% of the patients, and the remaining patients were treated with a pharmacological approach.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The prevalence of HS was 17%. We observed mild hypoxemia in 65% of the patients, moderate hypoxemia in 33% and severe hypoxemia in 1%. The left ventricle (LV) was dilated in 8% of the patients (LV end-diastolic volume, 103<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mL), and LV hypertrophy was found in 48% of the patients. The ejection fraction was 69% (SD, 6), and <span class="elsevierStyleSmallCaps">LV</span> systolic dysfunction was observed in only 3% of the patients. However, 68% of the patients presented diastolic dysfunction (type I, 53%; type II, 15%), with high <span class="elsevierStyleSmallCaps">LV</span> filling pressures in 6% of the cases.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In terms of valvular impairment, we observed aortic calcification in 31% of the patients and mitral calcification in 32% of the patients. Aortic stenosis was present in 5% of the patients (severe in 1 case and mild in the rest), aortic regurgitation in 12% (moderate in 1 case) and mitral regurgitation in 46% (all were mild except for 3% that were moderate). The left atrium was dilated in 53% of the patients. The pulmonary systolic blood pressure was 31<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg (SD, 7), with pulmonary hypertension in 22% of the cases (moderate in 1% and mild in the rest). The right ventricle (RV) was dilated in 22% of the patients, but RV systolic dysfunction was observed in only 2% of the patients.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We compared the population characteristics, echocardiographic findings and other factors of the overall population with those patients who specifically developed HS, but we observed no statistically significant differences. We observed HS resolution after liver transplantation in 84% of the patients and observed signs of syndrome permanence in 16%. Six patients died during the follow-up; however, 5 of them died during the first year after the liver transplantation, and all demonstrated at least moderate hypoxemia before the liver transplantation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The echocardiographic examination was determinant when assessing cardiac impairment in ESLD and when assessing the presence of HS, not only before the liver transplantation but also after the procedure. The prevalence of HS in our population, as well as the resolution rates, were similar to those described in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,5</span></a> The presence of cardiac repercussion, especially of LV hypertrophy, diastolic dysfunction and valvular calcification is common in patients with ESLD.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The presence of coronary artery disease will also be frequent in a selected group of these patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Cardiac studies should therefore be considered routine measures in assessing the potential causes and repercussions of liver disease. In the case of liver transplantation, cardiac studies should be accompanied by an assessment of the presence of HS both prior to and as follow-up to surgery.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Colunga Blanco SC, Corros Vicente C, García Campos A, de la Hera Galarza JM. Afectación cardiaca en pacientes con enfermedad hepática avanzada, más allá del síndrome hepatopulmonar. 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