Sequential assessment of liver stiffness in heart failure identifies cardiac cirrhosis

Introduction: Cardiac insufficiency may severely impair hepatic function either due to congestion or impaired perfusion eventually resulting in cardiac cirrhosis. Thus far, cardiac cirrhosis has been largely underestimated due to limitations in assessing fibrosis. We here assess cardiac fibrosis in patients with heart failure by seuqnetial determination of liver stiffness (LS) during recompensation therapy and analyze the cardiac and hepatic determinants of increased LS.

Methods and patients: In the retrospective learning cohort, 100 patients with acute decompensated heart failure were retrospectively analysed for hepatic abnormalities as evidenced by lab tests, ultrasound or LS (Fibroscan). In a second prospective validation cohort of 33 patients with acute heart failure, liver tests, echocardiography and LS were sequentially measured at the days of admission and release. Valid LS and complete data could be obtained in 14 patients for detailed analysis.

Results: In the learning cohort, 50 patients (50%) had an elevated GGT while elevated levels of AP, GOT, GPT and bilirubin were observed less frequently (n=27, 8, 12 and 19). LS exceeded 8 kPa in 14 of 21 patients (66.6%), which is considered as the cut-off value for advanced fibrosis (F3). In confirmation, 9 of 14 patients (64.2%) from the prospective validation cohort exceeded 8 kPa. LS decreased significantly during cardiac recompensation in 8 of these 9 patients from a mean of 22.2 kPa to 16.4 kPa (mean observation interval of 6.3 days). The decrease of LS correlated significantly with the weight loss. In 6 patients (42.8%), LS remained above 8 kPa despite a sufficient diuretic therapy. Ultrasound morphology further established cardiac cirrhosis in 5 of these patients. In this cirrhotic group, increased LS was excellently associated with bilirubin, NYHA state and GGT.

Conclusion: Sequential LS assessment allows to identify patients with cardiac cirrhosis. GGT – an established prognostic marker of heart failure- is drastically increased in the cirrhotic group. Thus, cardiac cirrhosis itself could be an important, hitherto underestimated progression factor in heart insufficiency e.g. via further water retention.