Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain.
J Hepatol. 2013 Jan;58(1):51-7. doi: 10.1016/j.jhep.2012.08.027. Epub 2012 Sep 16.
BACKGROUND & AIMS: The current study aimed at assessing the potential role of cardiac abnormalities in the pathogenesis of circulatory and renal dysfunction in cirrhosis.
One hundred and fifty-two patients (34 without ascites, 95 with ascites without renal failure and 21 with hepatorenal syndrome) were evaluated using Doppler echocardiography. In 102 patients, diastolic function was assessed by measuring parameters related to ventricular filling velocity, mitral annulus velocity and left atrial dimensions. Cardiopulmonary pressures were also measured by cardiac catheterization in 54 patients. In 50 additional patients, left ventricular myocardial strain was performed to estimate myocardial contractility and systolic function.
Grade 1 and 2 diastolic dysfunction was present in 41% and 16% of the patients, respectively. There was no patient with severe grade 3 diastolic dysfunction. Grade 2 diastolic dysfunction was associated with higher cardiopulmonary pressures but values were within the normal limits in all cases. Diastolic dysfunction directly correlated with liver failure but not with the degree of impairment in circulatory and renal function. The proportion of patients without or with grade 1 or 2 diastolic dysfunction was similar in patients with compensated cirrhosis, with ascites without renal failure or with hepatorenal syndrome despite marked differences in the degree of circulatory dysfunction, as indicated by plasma renin activity and noradrenaline concentration. The heart rate and systolic function were normal in all cases. There were no differences between patients without ascites, with ascites without renal failure or with HRS, despite marked differences in the activity of the renin-angiotensin system and sympathetic nervous system. These features indicate an impaired response of cardiac chronotropic and inotropic function to changes in systemic hemodynamics.
These data indicates that: (1) diastolic dysfunction is frequent in cirrhosis but in most cases it is of mild degree and does not increase the cardiopulmonary pressure to abnormal levels. This feature, which may be due to the central hypovolemia of cirrhosis, probably accounts for the lack of symptoms associated with this condition. (2) Diastolic dysfunction in cirrhosis is unrelated to circulatory dysfunction, ascites and HRS. (3) In cirrhosis, there is a lack of response of the left ventricular systolic and chronotropic function to peripheral arterial vasodilation and activation of the sympathetic nervous system and this feature is an important contributory factor to the progression of circulatory dysfunction and the pathogenesis of ascites and HRS.
本研究旨在评估心脏异常在肝硬化患者循环和肾功能障碍发病机制中的潜在作用。
对 152 名患者（34 名无腹水，95 名无肾功能衰竭性腹水，21 名肝肾综合征）进行多普勒超声心动图评估。在 102 名患者中，通过测量与心室充盈速度、二尖瓣环速度和左心房大小相关的参数评估舒张功能。在 54 名患者中还通过心导管测量心肺压力。在另外 50 名患者中，进行左心室心肌应变以评估心肌收缩力和收缩功能。
41%和 16%的患者分别存在 1 级和 2 级舒张功能障碍。无严重 3 级舒张功能障碍患者。2 级舒张功能障碍与较高的心肺压力相关，但所有病例均在正常范围内。舒张功能障碍与肝功能衰竭直接相关，但与循环和肾功能障碍的严重程度无关。在代偿性肝硬化、无腹水性肾功能衰竭或肝肾综合征患者中，无舒张功能障碍或 1 级或 2 级舒张功能障碍的患者比例相似，尽管循环功能障碍的程度存在明显差异，表现为血浆肾素活性和去甲肾上腺素浓度升高。所有病例的心率和收缩功能均正常。无腹水、无腹水性肾功能衰竭或 HRS 患者之间无差异，尽管肾素-血管紧张素系统和交感神经系统的活性存在明显差异。这些特征表明心脏变时和变力功能对全身血液动力学变化的反应受损。
这些数据表明：（1）肝硬化患者舒张功能障碍常见，但大多数为轻度且不会将心肺压力增加到异常水平。这种特征可能是由于肝硬化的中心性低血容量所致，可能是与该疾病相关的无症状原因。（2）肝硬化患者的舒张功能障碍与循环功能障碍、腹水和 HRS 无关。（3）肝硬化患者左心室收缩和变时功能对周围动脉扩张和交感神经系统激活无反应，这一特征是循环功能障碍进展和腹水及 HRS 发病机制的重要促成因素。
