Published online Aug 28, 2019. doi: 10.3748/wjg.v25.i32.4779
Peer-review started: April 22, 2019
First decision: May 9, 2019
Revised: June 10, 2019
Accepted: July 19, 2019
Article in press: July 19, 2019
Published online: August 28, 2019
Cardiovascular abnormalities occur in patients with liver cirrhosis. The prevalence of left ventricle diastolic dysfunction (LVDD) in cirrhotic patients ranges from 25.7% to as high as 81.4% as reported in different studies. In several studies the severity of diastolic dysfunction (DD) correlated with a degree of liver failure and the rate of dysfunction was higher in patients with decompensated cirrhosis compared with compensated. It is important to assess cardiac changes in especially those patients who are waiting for the liver transplantation, paracentesis or transjugular intrahepatic portosystemic shunt (TIPSS) implantation, because cardiovascular decompensation can be the main cause of operative failure.
Due to the lack of studies, well designed studies are necessary to determine the role of assesment of cardiac function in cirrhotic patients. Therefore, an attentive analysis of already performed studies on LVDD prevalence in cirrhotic patients is very important because LVDD has an influence on patients’ quality of life and their survival, especially in patients with advanced liver cirrhosis. Developing an appropriate treatment strategy for such patients also is the key to future research. Future directions of comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis to these patients so it is an attractive field of research.
The aim of our study was to clarify the association between the severity of liver cirrhosis and left ventricle diastolic dysfunction in the published studies.
In January and February, 2019 at Vilnius University we conducted a systematic review of the global existing literature on the prevalence of left ventricle diastolic dysfunction in patients with liver cirrhosis. We searched for articles in PubMed, Medline and Web of science databases. Eligibility criteria were: (1) Articles published in English only; (2) Only patients with liver cirrhosis diagnosed by clinical view, laboratory and imaging tests were included; (3) Severity of liver cirrhosis was evaluated by using Model for End-Stage Liver Disease score, (MELD score) or/and Child-Pugh classification A/B/C and scores; (4) Left ventricle diastolic function was evaluated by tissue Doppler imaging method; and (5) Left ventricle diastolic dysfunction was defined and its grading (I, II, III) classified according to ASE guidelines issued in 2009 or 2016. Analyses were performed to evaluate the ratio and grades of left ventricle diastolic dysfunction with respect to cirrhosis severity.
A total of 1149 articles and abstracts met the initial search criteria. 16 articles which met the predefined eligibility criteria were included in the final analysis. Overall, 1067 patients (out of them 723 men) with liver cirrhosis were evaluated for left ventricle diastolic dysfunction. In our systemic analysis we have found that 51.2% of cirrhotic patients had left ventricle diastolic dysfunction diagnosed and the grade 1 was the most prevalent (59.2 %, P < 0.001) among them, the grade 3 had been rarely diagnosed - only 5.1%. The data about the prevalence of diastolic dysfunction‘s prevalence in cirrhotic patients depending on Child-Pugh Classes was available from 5 studies (365 patients overall) and only 1 study found diastolic dysfunction being associated with severity of liver cirrhosis (P < 0.005). We established that diastolic dysfunction was diagnosed in 44.6% of Child-Pugh A class patients, in 62% of Child B class and in 63.3% of Child C patients (P = 0.028). The proportion of patients with higher diastolic dysfunction grades increases in more severe cirrhosis presentation (P < 0.001). There was no difference between mean MELD scores in patients with and without diastolic dysfunction. In all studies diastolic dysfunction was more frequent in patients with ascites (P = 0.04451). The influence of prophylactic treatment with of β-blockers on LVDD grade was not assessed in all of our chosen studies, but we think it may have had an impact on the cardiac function.
To our knowledge this is the first systematic review which summarizes the articles demonstrating the association between the severity of liver cirrhosis and LVDD. Our review of the existing literature allowed us to interpret the data supporting the correlation between the severity of liver cirrhosis evaluated by Child-Pugh classification and LVDD. Several studies in our review did not observe MELD scores, so we could not assess its‘ potential relation with LVDD. We highly recommend cardiac assessment of patients with Child-Pugh class B and C. Echocardiography should be done at least once in patients‘ case history, because these patients are at high risk of mortality. However, more extensive studies are needed for final and detailed conclusions.
Future directions of comprehensive assessment of cardiac function in cirrhotic patients might provide a better prognosis for such patients. We highly suggest that future clinical trials should evaluate how using of β-blockers in cirrhotics affects cardiac function, especially LVDD and its grade. In order to clarify the correlation between the severity of liver cirrhosis and LVDD and to elucidate the pathogenetic association between liver damages and cardiac impairment, the more large-scale prospective research is needed.