Letter to the Editor: Echocardiographic Predictors of a Worse Outcome in Patients With Liver Cirrhosis: What Should We Assess?
Authors: Roxana Cristina Rimbaş, Mihai Rimbaş, Dragoș Vinereanu
Journal: Hepatology (2019)

Potential conflict of interest: Nothing to report. To the Editor: We read with great interest the paper by Cesari et al.,1 a study of 115 patients with liver cirrhosis (LC) who were followed up for at least 6 years for fatal outcome and investigated by standard and tissue Doppler echocardiography to establish the prognostic value of different echocardiographic parameters. The strengths of the study are its prospective design, the large number of patients, the long follow‐up, and the comprehensive clinical and echocardiographic assessment focused mainly on diastolic dysfunction (DD). The diagnosis and grading of DD were made by comparative use of the classifications proposed by the American Society of Echocardiography, the European Association of Echocardiography, and the Thorax Center algorithm.1 The difference is striking: the prevalence of DD was 17% with the 2016 recommendations, 30% with the 2009 algorithm, and 48% using the Thorax Center algorithm, which emphasizes the idea of a major methodological issue in DD quantification. Moreover, the article did not present a subgroup analysis regarding the correlation of each DD grade with mortality. In multivariate analysis, none of the echocardiographic parameters were capable of predicting mortality when the Model for End‐Stage Liver Disease (MELD) score was also considered, and only the ratio between E wave from the mitral inflow profile to average diastolic mitral annular velocities (E/E′ ratio) and left atrial diameter (LAD) had a correlation when MELD was not considered. First of all, we suggest that indexed left atrial volume, which has been demonstrated to predict mortality better than LAD in a large population (10,719 patients),2 should be a mandatory measurement for DD assessment. Second, contrary to the authors’ suggestion that the E/E′ ratio can accurately estimate left ventricular filling pressure (LVFP), a recent meta‐analysis reported insufficient evidence to support it as a reliable parameter for the quantification of LVFP in patients with preserved ejection fraction.3 In our experience, the ratio of isovolumetric relaxation time/time from onset of E wave to onset of E′ wave predicts mortality better than the E/E′ ratio in the DD subgroup because it is independent of loading conditions.3 Third, patients with LC have different grades of DD not included in the current definition of cirrhotic cardiomyopathy (CCM). We consider it mandatory to correctly assess DD grades from mild to severe because the prognostic role of each grade should be judged separately1. Moreover, there are many tissue‐Doppler and speckle‐tracking echocardiographic parameters available for the estimation of ventricular function that are not yet included in the CCM definition, and there is evidence that stress echocardiography might be an important tool for CCM diagnosis because cardiac dysfunction becomes more evident in stressful conditions.3 In conclusion, the actual definition of CCM should be changed. DD grading should be based on a step‐by‐step multiparameter approach, not a simplified one. A standardized echocardiographic protocol is required for patients with LC in order to better predict mortality and potential complications in the short and long term as well as in the post–liver transplantation phase.