New insights in the pathogenesis of cirrhotic cardiomyopathy and the impact of left atrium strain

We read with great interest the review by Gananandan et al.1 regarding the current knowledge in the field of cirrhotic cardiomyopathy (CCM). As the authors pointed out, systemic inflammation is considered a crucial factor in the development of cardiac dysfunction mainly through increased intestinal permeability and endotoxaemia.1 At this point, we would like to mention an interesting finding from our recently published study,2 in which the presence of CCM was evaluated in 135 patients with cirrhosis using the Cirrhotic Cardiomyopathy Consortium criteria. Interestingly, for the first time in the literature, the association between CCM and total/visceral fat mass was evaluated and we found that patients with CCM, compared to patients without CCM, had higher values of total body fat (40% vs. 33.5%, p = .006), fat mass index (12 vs. 8.8 kg/m2, p = .005) and volume of visceral adipose tissue (735 vs. 641 cm3, p = .04).2 These findings are novel indicating that adipose tissue may also contribute to the development of CCM via the production of pro-inflammatory cytokines, hemodynamic disturbances, cardiac lipotoxicity and/or other mechanisms which need further investigation. Similar results from studies describing cardiac dysfunction in patients with obesity are reported in the literature demonstrating a strong crosstalk between heart and adipose tissue.3, 4 In addition, the authors include in their future perspectives on diagnostics of CCM the implementation of cardiac MRI.1 Cardiac MRI is an emerging technique that finds more and more applications in daily clinical practice. However, it has some limitations including that it is an expensive, time-consuming method, requires special facilities and specialized personnel and is not yet widely available in many centres. On the other hand, speckle tracking echocardiography is available in most ultrasound laboratories, is cost-effective, repeatable and does not require any contrast infusion or special preparation of the patient. Interestingly, in our study,2 we showed that reservoir strain of left atrium (LA), but not the strain of left ventricle, was significantly associated with the outcome of patients with cirrhosis. Reservoir strain of LA is considered a reliable and objective indicator of diastolic dysfunction.2 Consequently, although most studies have focused on the predictive value of left ventricular strain with contradictory results, LA strain could possibly be a useful prognostic indicator in patients with cirrhosis. In this context, speckle tracking echocardiography with LA evaluation (more than cardiac MRI) could be used as a new-sensitive diagnostic indicator of cardiac dysfunction, as well as predictive factor in the daily clinical routine. The authors do not have any disclosures to report. Data sharing is not applicable to this article as no data sets were generated or analysed during the current study.