Liver failure & cirrhosis
Cirrhotic cardiomyopathy, portopulmonary hypertension, hepatopulmonary syndrome — and the heart that caused the liver disease.
Echo approach, step by step
Cirrhosis produces a hyperdynamic circulation (low SVR, high output) and cirrhotic cardiomyopathy. Its 2019 consensus criteria are echocardiographic [208]. Echo also screens for portopulmonary hypertension and hepatopulmonary syndrome, which change transplant eligibility [204].
- Is the liver disease cardiac?IVC and hepatic veins, constriction criteria, TR, RV [4,57].
- Systolic functionLVEF and GLS [208].
- Diastolic functionSeptal e′, E/e′, LAVI, TR velocity [208].
- PASP and RVPortopulmonary hypertension screen [204].
- Saline studyLate bubbles (after ≥3 cycles) → intrapulmonary vascular dilatation (hepatopulmonary syndrome) [204].
- OutputLVOT VTI, CO (hyperdynamic) [170].
- Cardiac cause of liver disease excluded
- LVEF, GLS
- Diastolic criteria
- PASP, RV
- Saline study
- Cardiac output
Causes & echo clues
| Condition | Echo definition | Implication |
|---|---|---|
| Cirrhotic cardiomyopathy — systolic | LVEF ≤50% or absolute GLS <18% | Risk with TIPS, transplant and sepsis [208] |
| Cirrhotic cardiomyopathy — diastolic | ≥3 of: septal e′ <7 cm/s, E/e′ ≥15, LAVI >34 mL/m², TR >2.8 m/s | As above [208] |
| Portopulmonary hypertension | Raised PASP and RV dysfunction in portal hypertension | Right-heart catheterisation; severity affects transplant eligibility [204] |
| Hepatopulmonary syndrome | Late bubbles with hypoxaemia (raised A–a gradient) | Transplant indication [204] |
| Cardiac cirrhosis | Constriction, severe TR, RV failure | Treat the heart [57] |
Clinical pathway to the diagnosis
- Transplant or TIPS candidatesTTE with PASP estimate and saline study [204].
- Raised PASP or RV dysfunction→ right-heart catheterisation for PoPH [204].
- HypoxaemiaBlood gas (A–a gradient) plus saline echo for HPS [204].
- Raised JVP or unexplained ascites→ constriction and TR work-up [57].
Clinical pearls & pitfalls
Practical tipHigh output raises the TR velocity without raised PVR. Right-heart catheterisation distinguishes flow from resistance [204].
- Cirrhotic cardiomyopathy is often silent at rest and unmasked by stress: TIPS, transplant, infection [208].
Red flags
- Dyspnoea or hypoxaemia in cirrhosis → PoPH or HPS [204]
- Raised JVP → the liver disease may be cardiac (constriction, TR) [57]
- Pre-transplant or pre-TIPS assessment [204]