Cardiohepatic Interactions in Heart Failure an Overview
Data examining the direct effects of advanced HF therapies on end-organ liver damage are limited. Although hepatic injury, regardless of severity, is not an indication for initiation of advanced HF therapies, recent data suggest that liver function abnormalities improve after orthotopic cardiac transplantation. A small study (n = 56) demonstrated that patients who had chronic cardiac hepatopathy as defined by elevated GGT, alkaline phosphatase, and bilirubin had normalization of these values within 3 months after cardiac transplantation. The results of this study were later supported by another larger retrospective study, which showed that in a cohort of 617 patients undergoing heart transplantation, a significant proportion had abnormal LFTs that corrected after the procedure. Specifically, 38% and 68% of patients had pre-transplantation serum levels of alkaline phosphatase and GGT, respectively, that were pathologically elevated.
This analysis was also novel in that MELD (Model for End-Stage Liver Disease) and modMELD (modified MELD) scores in these patients were recorded pre-operatively and followed up for 5 years after transplantation. The proportion of patients with elevated MELD scores and intermediate MELD scores (>20 and 14 to 20, respectively) decreased 2 months after transplantation and stabilized by 1 year after transplantation. Similar trends were seen when the modMELD score was used to stratify this cohort. While these scores alone have not previously been used to select or disqualify patients for cardiac transplantation, they may provide clues to the presence of advanced liver disease. Patients with biochemical, clinical, or radiographic evidence of advanced disease should be thoroughly evaluated for the presence of cirrhosis. This evaluation typically involves a liver biopsy to identify/stage bridging fibrosis, and in advanced cases, the patient may be excluded from isolated cardiac transplantation due to the negative impact on post-transplantation outcomes. Combined heart-liver transplantation may be recommended for select cases of irreversible liver injury.
Effects of Advanced Heart Failure Therapies on Liver Function
Data examining the direct effects of advanced HF therapies on end-organ liver damage are limited. Although hepatic injury, regardless of severity, is not an indication for initiation of advanced HF therapies, recent data suggest that liver function abnormalities improve after orthotopic cardiac transplantation. A small study (n = 56) demonstrated that patients who had chronic cardiac hepatopathy as defined by elevated GGT, alkaline phosphatase, and bilirubin had normalization of these values within 3 months after cardiac transplantation. The results of this study were later supported by another larger retrospective study, which showed that in a cohort of 617 patients undergoing heart transplantation, a significant proportion had abnormal LFTs that corrected after the procedure. Specifically, 38% and 68% of patients had pre-transplantation serum levels of alkaline phosphatase and GGT, respectively, that were pathologically elevated.
This analysis was also novel in that MELD (Model for End-Stage Liver Disease) and modMELD (modified MELD) scores in these patients were recorded pre-operatively and followed up for 5 years after transplantation. The proportion of patients with elevated MELD scores and intermediate MELD scores (>20 and 14 to 20, respectively) decreased 2 months after transplantation and stabilized by 1 year after transplantation. Similar trends were seen when the modMELD score was used to stratify this cohort. While these scores alone have not previously been used to select or disqualify patients for cardiac transplantation, they may provide clues to the presence of advanced liver disease. Patients with biochemical, clinical, or radiographic evidence of advanced disease should be thoroughly evaluated for the presence of cirrhosis. This evaluation typically involves a liver biopsy to identify/stage bridging fibrosis, and in advanced cases, the patient may be excluded from isolated cardiac transplantation due to the negative impact on post-transplantation outcomes. Combined heart-liver transplantation may be recommended for select cases of irreversible liver injury.