UCLA

Background: Diastolic dysfunction is a relatively common abnormality of the heart in the general population, and occurs at least as often in patients with advanced cirrhosis. Diastolic dysfunction is considered to be a hallmark finding in cirrhotic cardiomyopathy, which is a set of changes in the heart seen in advanced liver disease. We hypothesized that diastolic dysfunction, evidenced by abnormal lateral mitral annular tissue Doppler velocity, would negatively impact survival after liver transplant.

Methods: We performed a retrospective chart review of consecutive adult patients undergoing orthotopic liver transplantation at our institution with available pre-transplant echocardiograms over a ten-year period. The primary outcome was overall post-transplant survival. Cox proportional hazards model was utilized to evaluate the effect of diastolic dysfunction on survival, controlling for covariates previously known to be associated with survival. The benefit of inclusion of tissue Doppler velocity as a marker of diastolic dysfunction in the survival model was assessed with a likelihood ratio test as well Harrell’s C-statistic and was compared with other previously reported diastolic parameters.

Results: Over the ten-year study period, 663 patients met inclusion criteria, 135 (20.4%) of whom had abnormal tissue Doppler velocities. Those with abnormal tissue Doppler tended to be slightly older, more often female, and have coronary disease or risk factors such as diabetes, hypertension, or renal disease. Otherwise, the abnormal and normal groups were well matched in etiology of cirrhosis, model for end-stage liver disease (MELD) scores, and markers of severity of illness including need for vasopressors, dialysis, and mechanical ventilation. After a median follow-up of 36.2 months, abnormal tissue Doppler velocity was shown to have a strong, negative association with survival (hazard ratio [HR] 1.91, p <0.0001) in a model that included race, hepatitis C infection, need for dialysis and mechanical ventilation, recipient age, donor age, and MELD. Other variables that were found to be significant included hepatitis C infection (HR 1.46, p = 0.01) and need for dialysis (HR 1.37, p = 0.049).

Conclusions: In summary, we find that diastolic dysfunction, as evidenced by abnormal tissue Doppler velocity, is a common abnormality in liver transplant patients and is independently associated with decreased survival. Compared with clinical comorbidities included in the model, it was the most strongly associated with reduced survival, and performed better than other previously published diastolic parameters. Further studies are needed in a multi-center, prospective manner to confirm these findings and clarify the role of diastolic dysfunction in the pre-transplant evaluation of patients.