Blunted cardiac reserve as a marker of cirrhotic cardiomyopathy—Cardiac outcomes following liver transplantation and comparison to the existing guidelines

Cirrhotic cardiomyopathy (CCM) is an underrecognized risk factor for cardiac events in patients undergoing liver transplantation (LT). Blunted cardiac reserve (BCR) is an emerging indicator of CCM, although it has not been integrated into diagnostic guidelines. This study assesses posttransplant cardiac outcomes and mortality in patients with BCR compared with current CCM diagnostic guidelines, focusing on diastolic indices. Consecutive patients undergoing liver transplant assessment were included. Of 978 patients screened with dobutamine stress echocardiography between 2010 and 2023, 481 (58.0%) progressed to LT, with 183 (38.0%) meeting BCR criteria and 117 (24.3%) meeting existing CCM diagnostic criteria. Thirty (6.2%) patients experienced a 30-day major adverse cardiovascular event (MACE), and 92 patients (19.1%) died on long-term follow-up. Following multivariate regression analysis, BCR was the strongest independent risk factor for postoperative MACE (hazards ratio [HR], 2.57; 95% CI, 1.13-5.85; P = .024), heart failure exacerbations (HR, 6.93; 95% CI, 1.46-33.01; P = .015), and 30-day mortality (HR, 9.69; 95% CI, 1.04-92.33; P = .049). Addition of BCR to the existing guidelines improved MACE prediction (HR, 5.81; 95% CI, 1.71-19.76; vs 2.59; 95% CI, 1.15-5.87; P = .006), with a net reclassification improvement index of 41.9% (P = .004) compared with existing guidelines alone. These results support the integration of a cardiac reserve assessment into CCM diagnostic criteria and use in risk stratification of patients undergoing LT.