Medical Care
No prospective studies have been performed to evaluate the medical treatment of cardiac cirrhosis. Because no data suggest that the presence of cardiac cirrhosis worsens mortality or morbidity rates, direct treatment at the underlying source of elevated right-sided heart pressure and hepatic venous congestion.
Note the following:
-
Initiate treatment in an inpatient setting, both to rule out ischemic heart disease and to administer IV diuretics.
-
In most cases, diuresis is the cornerstone of initial medical therapy for symptomatic relief.
-
Once the patient is euvolemic, beta-blockers and ace inhibitors should be added if the underlying cause is left ventricular dysfunction.
-
Spironolactone should be considered, especially if there is New York Heart Association class III or IV heart failure.
Consult with specialists in cardiology, gastroenterology, and diet and/or nutrition.
Surgical Care
Definitive treatment of cardiac cirrhosis sometimes requires surgical intervention, particularly when the underlying structural or anatomic lesion remains symptomatic despite maximal medical therapy.
Examples of surgical intervention include the following:
-
Coronary artery bypass surgery or percutaneous transluminal coronary angioplasty for ischemic cardiomyopathy
-
Tricuspid valve repair or replacement for tricuspid regurgitation or tricuspid stenosis
-
Pericardiectomy (cardiac decortication) for constrictive pericarditis
-
Peritoneovenous shunt not indicated to treat cardiac ascites
-
Transjugular intrahepatic portosystemic shunt (TIPSS): This is generally contraindicated because of the risk of acute right-sided decompensation from increased venous return. One recent case report illustrated the use of TIPSS procedure in a patient with cardiac cirrhosis after heart transplant that resulted in a successful outcome. [13]
-
Cardiac transplantation can be considered for end-stage cardiomyopathy. The presence of cardiac cirrhosis with significant liver fibrosis is considered a contraindication to transplantation. Although standard transplant criteria applies, several caveats should be considered. First, right-heart failure can be accompanied by significant pulmonary hypertension, which may necessitate combined heart-lung transplant. Second, synthetic liver function may be affected, leading to bleeding complications associated with transplantation. However, a study examining the reversibility of cardiac cirrhosis in patients undergoing heart transplant showed that synthetic function significantly improved within 3 months after transplant. [14]
Diet
Sodium restriction is a fundamental component of long-term management. The sodium intake goal is less than 2 g/d.
Activity
A sensible exercise program is appropriate for most patients with cardiac cirrhosis after medical control of their underlying heart failure.
Long-Term Monitoring
Instruct patients to maintain a diary of their daily weights. Specific instructions may be issued to increase the patient's oral diuretic dose, as well as to return for immediate medical evaluation when certain weight increases are exceeded (eg, 2 lb/d or 5 lb/wk).
Schedule periodic follow-up. Monitor symptoms, preferably using well-defined activities (eg, walking 100 ft on ground level, climbing 1-2 flights of stairs).
Follow serum levels of potassium, blood urea nitrogen (BUN), creatinine, aspartate aminotransaminase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]), alanine aminotransferase (ALT) (serum glutamic-pyruvic transaminase [SGPT]), alkaline phosphatase (ALP), and total bilirubin. All should normalize with attainment of heart failure compensation. Failure of levels to resolve despite heart failure resolution should prompt evaluation of noncardiac sources of liver disease.
-
Cardiac cirrhosis and congestive hepatopathy. Congestive hepatopathy with large renal vein.
-
Cardiac cirrhosis and congestive hepatopathy. Congestive hepatopathy with large inferior vena cava.
