Diastolic Dysfunction Is a Predictor of Poor Survival in Patients with Decompensated Cirrhosis

Background. Left ventricular diastolic dysfunction (LVDD) appears to be the earliest cardiac disturbance in cirrhosis patients. There are many previous reports reporting the significance of severity of LVDD on the outcome of liver transplantation or TIPS insertion, a few Indian studies have addressed the role of LVDD on survival in decompensated cirrhosis. The objective of this study is to assess the effect of LVDD on the survival of decompensated cirrhotic patients. Methods. We prospectively evaluated 92 decompensated cirrhotic patients from April 2015 to March 2017 at IMS and SUM Hospital, Bhubaneswar, India. 2D echocardiography with tissue Doppler imaging was used to evaluate cardiac function, as per the American society of echocardiography guidelines. The primary endpoint was to evaluate the effect of LVDD on overall mortality. Results. Ninety-two decompensated cirrhotic patients were evaluated in this prospective cohort study. Twenty-eight out of 92 patients (30%) died due to liver-related complications after a follow-up of 24 months. The decompensated cirrhotic patients with <a:math xmlns:a="http://www.w3.org/1998/Math/MathML" id="M1"> <a:mtext>MELD</a:mtext> <a:mtext> </a:mtext> <a:mtext>score</a:mtext> <a:mo>≥</a:mo> <a:mn>15</a:mn> </a:math> had a significantly higher <c:math xmlns:c="http://www.w3.org/1998/Math/MathML" id="M2"> <c:mi>E</c:mi> <c:mo>/</c:mo> <c:msup> <c:mrow> <c:mi>e</c:mi> </c:mrow> <c:mrow> <c:mo>′</c:mo> </c:mrow> </c:msup> </c:math> ratio ( <e:math xmlns:e="http://www.w3.org/1998/Math/MathML" id="M3"> <e:mn>11.94</e:mn> <e:mo>±</e:mo> <e:mn>4.24</e:mn> </e:math> vs. <g:math xmlns:g="http://www.w3.org/1998/Math/MathML" id="M4"> <g:mn>8.74</g:mn> <g:mo>±</g:mo> <g:mn>3.32</g:mn> </g:math> , <i:math xmlns:i="http://www.w3.org/1998/Math/MathML" id="M5"> <i:mi>p</i:mi> <i:mo><</i:mo> <i:mn>0.001</i:mn> </i:math> ) suggesting severe LV dysfunction in advanced cirrhosis. Patients with <k:math xmlns:k="http://www.w3.org/1998/Math/MathML" id="M6"> <k:mi>E</k:mi> <k:mo>/</k:mo> <k:msup> <k:mrow> <k:mi>e</k:mi> </k:mrow> <k:mrow> <k:mo>′</k:mo> </k:mrow> </k:msup> <k:mtext> </k:mtext> <k:mtext>ratio</k:mtext> <k:mo>></k:mo> <k:mn>10</k:mn> </k:math> had significantly higher MELD score and Child-Pugh score ( <m:math xmlns:m="http://www.w3.org/1998/Math/MathML" id="M7"> <m:mn>19.88</m:mn> <m:mo>±</m:mo> <m:mn>7.72</m:mn> </m:math> vs. <o:math xmlns:o="http://www.w3.org/1998/Math/MathML" id="M8"> <o:mn>14.31</o:mn> <o:mo>±</o:mo> <o:mn>5.83</o:mn> </o:math> ; <q:math xmlns:q="http://www.w3.org/1998/Math/MathML" id="M9"> <q:mn>10.25</q:mn> <q:mo>±</q:mo> <q:mn>1.74</q:mn> </q:math> vs. <s:math xmlns:s="http://www.w3.org/1998/Math/MathML" id="M10"> <s:mn>9.02</s:mn> <s:mo>±</s:mo> <s:mn>1.74</s:mn> </s:math> , <u:math xmlns:u="http://www.w3.org/1998/Math/MathML" id="M11"> <u:mi>p</u:mi> <u:mo><</u:mo> <u:mn>0.01</u:mn> </u:math> , respectively) as compared to the <w:math xmlns:w="http://www.w3.org/1998/Math/MathML" id="M12"> <w:mi>E</w:mi> <w:mo>/</w:mo> <w:msup> <w:mrow> <w:mi>e</w:mi> </w:mrow> <w:mrow> <w:mo>′</w:mo> </w:mrow> </w:msup> <w:mtext> </w:mtext> <w:mtext>ratio</w:mtext> <w:mo><</w:mo> <w:mn>10</w:mn> </w:math> group. In Cox proportional hazard multivariate analysis, <y:math xmlns:y="http://www.w3.org/1998/Math/MathML" id="M13"> <y:mi>E</y:mi> <y:mo>/</y:mo> <y:msup> <y:mrow> <y:mi>e</y:mi> </y:mrow> <y:mrow> <y:mo>′</y:mo> </y:mrow> </y:msup> <y:mo>≥</y:mo> <y:mn>10</y:mn> </y:math> (HR 2.72, 95% CI 1.07-6.9, <ab:math xmlns:ab="http://www.w3.org/1998/Math/MathML" id="M14"> <ab:mi>p</ab:mi> <ab:mo>=</ab:mo> <ab:mn>0.03</ab:mn> </ab:math> ) and serum albumin (HR 0.32, 95% CI 0.14-0.7, <cb:math xmlns:cb="http://www.w3.org/1998/Math/MathML" id="M15"> <cb:mi>p</cb:mi> <cb:mo><</cb:mo> <cb:mn>0.01</cb:mn> </cb:math> ) were found to be independent predictors of mortality in decompensated cirrhotic patients. Conclusion: The presence of LVDD and low serum albumin were independent predictors of mortality in decompensated cirrhotic patients. Hence, LVDD is an indicator of advanced cirrhosis and mortality.