Complexity of Hemodynamic Assessment During Shock in Cirrhosis

Hemodynamic assessment is complex in cirrhosis because of a multitude of abnormalities including decreased vasomotor tone, decreased peripheral vascular resistance, increase baseline cardiac output, and diastolic dysfunction in addition to complex cardio-hepatic interactions including portopulmonary hypertension and cardiac electrical abnormalities. Despite increased cardiac output sometimes patients with cirrhosis show an attenuated systolic dysfunction in the setting of pharmacological and physiological stress. In cirrhosis systolic dysfunction is related to mortality and hemodynamic complications like HRS. The left ventricular ejection fraction (LVEF) is the most frequently used parameter to assess systolic function. Activation of the renin-angiotensin system (RAS) in response to splanchnic vasodilatation leads to increased sodium retention and affects the loading condition, which may mask systolic dysfunction when afterload is severely decreased in patients with cirrhosis. This section will highlight the consideration of these complex interactions while interpreting the hemodynamic state and the choice of therapy in cirrhosis.

Xanthopoulos A, Starling R, Kitai T, et al. Heart Failure and Liver Disease. J Am Coll Cardiol HF. 2019 Feb, 7 (2) 87–97.https://doi.org/10.1016/j.jchf.2018.10.007

Murray Jf, Dawson Am, Sherlock S. Circulatory changes in chronic liver disease. Am J Med. 1958 Mar;24(3):358-67. doi: 10.1016/0002-9343(58)90322-x. PMID: 13520736.

Kwon, H.-M., Moon, Y.-J., Jung, K.-W., Park, Y.-S., Kim, K.-S., Jun, I.-G., Song, J.-G. and Hwang, G.-S. (2020), Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post–Liver Transplantation Mortality. Hepatology, 71: 1364-1380. https://doi.org/10.1002/hep.30913

Gassanov N, Caglayan E, Semmo N, Massenkeil G, Er F. Cirrhotic cardiomyopathy: a cardiologist's perspective. World J Gastroenterol. 2014 Nov 14;20(42):15492-8. doi: 10.3748/wjg.v20.i42.15492. PMID: 25400434; PMCID: PMC4229515.