2009 Southern Regional Meeting Abstracts

Case Report: A 68 year old white male with a history of cryptogenic cirrhosis was admitted for orthotopic liver transplantation (OLT). A dobutamine stress echocardgiogram obtained pre-operatively for cardiac risk stratification demonstrated normal systolic function with an ejection fraction (EF) of 60% without wall motion abnormalities. Stress images did not demonstrate focal wall motion abnormalities and EKGs also failed to demonstrate findings concerning for ischemia. He subsequently underwent successful OLT. On post operative day four he developed shortness of breath, lower extremity edema, and orthopnea. Cardiac bio-markers, EKG, and repeat transthoracic echocardiogram (TTE) were obtained. Cardiac enzymes returned normal and EKG was unchanged from pre-operative assessment. TTE demonstrated a depressed EF at 30% with global hypokinesis, but no focal wall motion abnormalities. His heart failure was treated medically with Furosemide, Metoprolol and Lisinopril with improvement in his symptoms over the next two days. He was discharged on the same medical regimen.
Patients with advanced cirrhosis and end stage liver disease possess a hyperdynamic circulatory state. This hyperdynamic state is the result of an increased resting cardiac output and peripheral vasodilitation. The peripheral vasodilatation exists despite elevated levels of noradrenaline, angiotensin II, and other vasoactive peptides. This suggests that cirrhotics have an impaired response to serum vasopressors. Infusion of Endothelin-1 illicited a vasodilatory response in cirrhotics as opposed to controls where the expected vasoconstrictive response occurred. This response corrected in patients undergoing OLT. This post OLT correction produces an increase in systemic vascular resistance. This abrupt change in afterload can precipitate systolic dysfunction and heart failure.
The prognosis of post liver transplant systolic dysfunction and heart failure is largely unknown. Over time the heart may adapt to this increase in afterload and have improvement of systolic function. A small set of patients undergoing transplantation at the Mayo Clinic demonstrated improvement in EF over a 15 month follow up, though never completely returning to pre-operative levels. Initial treatment should focus on treatment of CHF symptoms while monitoring for return of systolic function.