Liver cirrhosis, a chronic condition often culminating in the need for liver transplantation, presents complex systemic consequences beyond hepatic impairment. As surgical and pharmacological management of liver disease has improved, cardiovascular complications have become a more prominent cause of morbidity and mortality following transplantation. In this context, understanding the cardiac manifestations of cirrhosis is vital.
While cirrhotic cardiomyopathy has traditionally been associated with systolic and diastolic dysfunction, its diagnostic boundaries remain poorly defined. A recent study employed cardiac magnetic resonance (CMR) imaging to investigate structural and functional cardiac changes in patients with liver cirrhosis awaiting transplantation. It also aimed to assess myocardial tissue characteristics and stress perfusion, comparing findings with healthy controls. Importantly, it examined the relationship between cardiac parameters and liver disease severity using established clinical scoring systems.
Functional Hypercontractility and Ventricular Dilatation
In contrast to previous expectations of impaired systolic function in cirrhotic cardiomyopathy, patients with liver cirrhosis in this study demonstrated enhanced ventricular function. Both left and right ventricular ejection fractions were significantly higher compared to age and sex-matched healthy individuals. These findings were supported by elevated stroke volumes and more pronounced global longitudinal strain. Notably, end-diastolic volumes of the left ventricle were significantly increased, indicating a state of chamber dilatation. Right ventricular volumes were also higher, though not to a statistically significant extent, possibly due to sample size limitations. Left atrial volumes were similarly elevated in cirrhosis patients, reflecting atrial remodelling. The right atrium did not show the same degree of enlargement.
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These patterns suggest that cirrhosis induces a hyperdynamic circulatory state, likely driven by systemic vasodilatation, decreased peripheral resistance and compensatory neurohumoral activation. The result is increased cardiac output and contractility, accompanied by elevated preload. Such a response, commonly linked to portal hypertension, challenges the current definition of cirrhotic cardiomyopathy, which emphasises reduced function. The presence of hypercontractility in the setting of liver dysfunction indicates a more complex and dynamic interaction between hepatic and cardiac systems.
Fibrotic Indicators and Disease Severity Correlation
Beyond structural and functional parameters, CMR imaging enabled detailed tissue characterisation. T1 and T2 relaxation times did not differ significantly between groups, yet extracellular volume (ECV) analysis revealed informative patterns. While absolute ECV values remained within normal ranges, a strong positive association emerged between ECV and the severity of liver disease. Higher Child-Pugh classes and MELD scores were correlated with increased ECV, indicating the progressive accumulation of myocardial fibrosis as liver function declines.
Furthermore, non-ischemic late gadolinium enhancement (LGE) was identified in 20% of cirrhosis patients. These enhancements primarily appeared in basal to mid-ventricular regions, often with a linear or patchy distribution in the mid-myocardial and inferior walls. The presence of LGE without signs of ischaemia suggests a fibrotic process independent of coronary artery disease. These findings support the hypothesis that cirrhotic heart disease involves structural changes even in the absence of overt functional deterioration.
Interestingly, despite the presence of fibrosis, the overall extracellular volume did not differ significantly between patients and controls when averaged across the cohort. This may reflect the fact that most participants were classified as Child-Pugh class B, representing a more compensated disease state. Still, the upward trend in ECV in relation to disease severity underlines the importance of fibrosis as a pathophysiological marker in cirrhotic patients.
Perfusion Findings and Clinical Implications
Despite a known high prevalence of cardiovascular risk factors such as hypertension and diabetes among liver cirrhosis patients, none of the subjects who underwent stress testing displayed myocardial perfusion deficits. This is noteworthy given prior assumptions that liver disease increases susceptibility to coronary artery disease. Although coronary lesions may exist, their functional impact in this cohort appeared limited. Previous literature also reports a low frequency of functionally relevant ischaemia in similar populations. These results suggest that routine perfusion imaging may not always be necessary for pre-transplant evaluation, particularly when the goal is to detect ischaemia severe enough to influence surgical eligibility.
The identification of structural and fibrotic changes in the absence of perfusion abnormalities calls for a re-evaluation of current screening protocols. The traditional focus on ejection fraction and perfusion may overlook subclinical cardiac involvement that can still influence outcomes. As fibrosis progresses, even in patients with preserved function, the risk of postoperative complications may rise. Therefore, CMR offers valuable insights that could complement standard risk stratification tools in transplant candidates.
The investigation provides compelling evidence that liver cirrhosis induces distinct cardiac alterations, including ventricular dilatation, functional hypercontractility and myocardial fibrosis. These changes are not always accompanied by perfusion deficits, despite common cardiovascular risk factors. The association between disease severity scores and markers of fibrosis further emphasises the systemic impact of advanced liver disease. Importantly, the findings challenge conventional diagnostic criteria for cirrhotic cardiomyopathy by demonstrating that cardiac function may be preserved or even enhanced in many cases. CMR emerges as a sensitive modality for detecting subtle yet clinically significant cardiac changes in this population, supporting its broader use in pre-transplant cardiac assessment.
Source: European Radiology
Image Credit: iStock
