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.