CARDIAC CIRRHOSIS AND RIGHT-SIDED HEART FAILURE
Dediu G.N., Ristoiu L.E., Constantinescu R.
1 Internal Medicine, Emergency Clinical Hospital,Sfantul Ioan, Bucharest
2 University of Medicine and Pharmacy Carol Davila, Bucharest
Background
Cardiac cirrhosis is a term used to include the spectrum of
hepatic disorders that occur secondary to passive hepatic
congestion due to cardiac dysfunction, especially the right
heart chambers. Cardiac cirrhosis can be caused by any right
sided pathology that can generate right heart failure that
causes an increase in venous congestion and increase of
pressure in the hepatic sinusoid. The cardiac abnormalities
that can lead to hepatic congestion are: valvular disease
(mitral stenosis, tricuspid regurgitation), severe pulmonary
hypertension, cor pulmonale, biventricular heart failure or
pericardial diseases as cardiac tamponade, and constrictive
pericarditis.
Right-sided heart failure secondary to left-sided heart failure,
valvular diseases (tricuspid regurgitation, mitral stenosis) or
decreases in relaxation or filling of the right sided heart as in
the setting of constrictive pericarditis, can produce an
increase in the preload and backflow to the hepatic system
producing hepatic congestion.
Objectives
The aim of our study was to review published studies that
present the causes of cardiac cirrhosis due to right-sided
heart failure and the signs and symptoms.
Methods and Materials
The Pubmed, Medline, Embase databases were
systematically searched for studies regarding heart
failure and cardiac cirrhosis, due to hepatic congestion.
We analyzed several articles and we have outlined our
findings. Reference lists of retrieved articles were also
checked to identify additional articles.
Heart failure is a complex clinical syndrome associated with
symptoms of dyspnea, fatigue, and peripheral and/or
pulmonary edema. Although there have been dramatic
innovations in medical and device treatments for heart
failure in recent decades, the incidence of heart failure is
increasing. The heart failure syndrome affects an estimated
5.7 million Americans and more than 23 million people
worldwide. The heart failure epidemic has a staggering
impact on quality of life, functioning, and longevity, while
imposing heavy costs on the health care system.
Liver disease is common in patients with advanced heart
failure and can significantly impact morbidity and mortality.
It is difficult to diagnose severe liver disease, including
hepatic fibrosis and cirrhosis, in advanced heart failure
based on history, physical examination, and imaging
studies. Liver disease is a common sequela of advanced
heart failure, ranging from mild reversible liver injury to
hepatic fibrosis and, in its most severe form, cardiac
cirrhosis.
Results
The severity and characteristics of liver injury depend on
the vessels involved and correspond to hepatic
congestion and reduced perfusion. In the cirrhotic liver,
distortion of the normal liver architecture is caused by
structural and vascular changes. Portal hypertension is
often associated with a hyperdynamic circulatory
syndrome in which cardiac output and heart rate are
increased and systemic vascular resistance is decreased.
The release of several vasoactive substances is the
primary factor involved in the reduction of mesenteric
arterial resistance, resulting in sodium and water
retention with eventual formation of ascites.
Heart failure symptoms are prominent and often mask
gastrointestinal symptoms. Symptoms of heart failure
include those due to excess fluid accumulation (dyspnea,
orthopnea, edema, pain from hepatic congestion, and
abdominal distention from ascites) and those due to a
reduction in cardiac output (fatigue, weakness) that is
most pronounced with physical exertion. Oedema
typically occurs in the lower extremities and dependent
regions and may progress to anasarc oedema in advanced
and untreated patients.The distention of the neck veins is
also very common. The anorexia is secondary to several
factors including a poor perfusion of the splanchnic
circulation, bowel edema, and nausea induced by hepatic
congestion.
Hepatomegaly usually presents as a hard, firm liver, and
there is also a possibility of splenomegaly. Fewer than
10% of all patients exhibit jaundice. The blood test
should include: Cardiac troponin (T or I), complete blood
count, serum electrolytes, blood urea nitrogen, creatinine,
liver function test and brain natriuretic peptide (BNP).
BNP (or NT-proBNP) level adds greater diagnostic value
to the history and physical examination than other initial
tests mentioned above. The most common abnormality in
the blood test is the mild bilirubin growth. Changes in
transaminases and alkaline phosphatase also occur and
albumin is reduced in 30-50% of patients, but it is not
usually less than 2.5 g/dL. There are also frequent
coagulation disorders.
Characteristic features:
Pulsus alternans phenomenon characterized by evenly
spaced alternating strong and weak peripheral pulses.
Apical impulse: laterally displaced past the
midclavicular line, usually indicative of left
ventricular enlargement.
S3 gallop: a low-frequency, brief vibration occurring
in early diastole at the end of the rapid diastolic filling
period of the right or left ventricle. It is the most
sensitive indicator of ventricular dysfunction.
The imaging investigations needed for diagnosis are:
chest X-ray, cardiac and abdominal ultrasound, MRI and
CT. Needle biopsy is indicated in cases where the
diagnosis is not clear and in the case of liver transplant
candidates.
Conclusions
There is no specific therapy for cirrhotic
cardiomyopathy and the treatment should be supportive
and addressed to the cardiac dysfunction.
Prognosis depends on the evolution of disease that led to
cardiac cirrhosis.
Due to common signs and symptoms of the biliary
disease, imaging evaluation should be considered.
Abdominal ultrasound for evaluation of the biliary tract
and gallbladder can rule out acute obstructive disease or
hepatic vein thrombosis.
The treatment of cardiac cirrhosis is based on
management of the underlying cardiac condition causing
hemodynamic unbalance. Determination of the volume
status and adequate management of fluids for these
patients is important. Clinical features of cardiac cirrhosis
may improve dramatically with adequate diuresis.
Close monitoring of cardiac output is important to
prevent ischemic hepatitis. Use of chronotropic agents or
supportive pump can be considered.
Heart failure disease management is a complex
condition that requires a multidisciplinary framework for
the care of patients, including discharge planning, patient
education, and frequent outpatient assessment.
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