Real Time Pressure Volume Loops in Cirrhosis: Characterization of Systolic and Diastolic Function and Validation of Doppler Indices with the Gold Standard

Studies reporting abnormal left ventricular (LV) properties in cirrhosis have frequently used load-dependent indices. Aims: 1) to evaluate systolic and diastolic LV properties with the gold standard, LV conductance catheter, which allows obtention of real-time pressure volume loops, 2) to test the validity of Doppler-echocardiography indices compared to the gold standard, 3) to analyze the impact of severity of liver disease, neurohormonal activation and beta-blocker (BB) treatment on LV properties.

Methods: Pressure-volume loops were obtained in 9 patients with cirrhosis (Child A:3;B:2;C:4; refractory ascites:2) in the context of liver transplant evaluation and 9 controls undergoing LV catheterization. Invasive gold-standard systolic (maximal elastance, Emax) and diastolic indexes (relaxation and stiffness) were correlated to Doppler-echocardiography indices including peak ejection intraventricular pressure difference (EIVPD) and strain rate (SR). Gold-standard validated Doppler indexes in cirrhosis (n = 59; Child A:15;B:25;C:19; refractory ascites:9) were compared to matched controls. The influence of the severity of liver disease, neurohormonal activation and BB was evaluated. Nonparametric tests were used. IRB approval was obtained.

Results: Emax correlated only with EIPVD (r = 0.75, p < 0.01) and SR (r = 0.55, p = 0.02). No correlation was observed between Emax and ejection fraction (r =-0.18, p = 0.47), cardiac output (r = 0.3, p = 0.23) or dP/dtmax (r = 0.06, p = 0.81). Doppler indices of diastolic function (such as E/E') failed to correlate with reference indices of relaxation and stiffness. E/A correlated with end-diastolic pressure, which is associated to preload (R = 0.61 p = 0.009 for E/A). In 59 patients with cirrhosis, EIVPD was higher than in matched controls (p < 0.05), and was related to the severity of liver disease (Child class p = 0.01; MELD R = 0.45 p < 0.001), noradrenaline (R = 0.26, p = 0.05) and heart rate variability (SDNN, R =-0.43 p = 0.003). Patients with no ascites, diuretic responsive and refractory ascites had increasing EIPVD (p = 0.026) with no differences in SR (p = 0.848). E/A ratio was associated to Child class (p = 0.04). Patients on BB (n = 33) had lower peak EIVPD and SR (systolic), although higher than controls. Deceleration time (diastolic function) was significantly longer in patients on BB.

Conclusions: Gold-standard indices of systolic function are increased in patients with cirrhosis. Systolic function as measured by validated Doppler indices in cirrhosis is increased compared to controls, even in refractory ascites. Noninvasive indices of diastolic function reflect LV filling pressures, but not gold-standard indices of diastolic function.

Corresponding author: Ripoll, Cristina

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