Left ventricular diastolic dysfunction: a surrogate predictor of poor transplant-free survival in patients with decompensated cirrhosis

Abstract

Background and Aim: Left Ventricular Diastolic Dysfunction (LVDD) is a primal manifestation of Cirrhotic Cardiomyopathy. Few studies have addressed its relationship with mortality outcomes. We evaluated the impact of LVDD along with other parameters on the short-term survival of patients with Decompensated Cirrhosis. Methods: 192 patients with Decompensated Cirrhosis underwent investigations including 2D echocardiography with Tissue Doppler imaging. The diagnosis of LVDD was based on the American Society of Echocardiography guidelines and the patients were followed up for 6 months. Results: 42.2% (n=81) had grade 1 LVDD and 30.7%(59) had grade 2 LVDD at enrolment. 69.2%(128) were alive at 6 months. Among the non-survivors, 5.9% had no LVDD, 23.4% had grade-1 and 62.1% had grade-2 LVDD (p=<0.001). Median survival of LVDD grades 0, 1, and 2 was 177±3, 163±3, and 122±3 days respectively. Kaplan Meier survival analysis showed poor survival in patients with LVDD (p<0.001), E/e'>10 (p=0.029) and PCWP >15mmHg (p=0.003). The Cox regression model showed a hazard ratio of 10.3 for grade-2 LVDD, and 5.7 for any LVDD compared to 1.07 for MELD score as an independent predictor of mortality. MELD score cut-off for predicting mortality was 17 (84% sensitivity; 62% specificity). Mortality in patients with MELD >17 was 52.9% with LVDD vs 9.5% without LVDD (p<0.001), and MELD >17 was 16.7% with LVDD vs 3.4% without LVDD(p=0.08). In multivariate analysis, the MELD score and LVDD were independent predictors of survival. Among echocardiography parameters, patients with a ratio of early filling velocity to early diastolic mitral annular velocity(E/e') >10 and Pulmonary capillary wedge pressure(PCWP) >15mmHg were significantly associated with the severity and mortality of the patients. Conclusions: The presence and severity of LVDD are better predictors of poor transplant-free survival than MELD in patients with Decompensated Cirrhosis. Therefore, cardiac parameters could be an add-on to the MELD score for prognostication of Decompensated Cirrhosis patients.