cardio-hepatic syndrome organ dysfunction in acute heart ......nikolaou et al eur heart journal 2013...

Organ dysfunction in acute heart failure:Cardio-hepatic syndrome

Alexandre MebazaaDepartment of Anesthesia & Critical Care

University Hospitals Saint Louis – Lariboisière, Paris, France University Paris 7; INSERM – UMR 942

Conflict of interest

• Speaker’s bureau Alere, Edwards, Thermofischer

• Consultant for Bayer, Cardiorentis, Novartis, Orion, Vifor Pharma

Short version: HFA/EUSEM/SAEM Eur Heart Journal 2015; Long version: Eur J Heart Failure 2015

Online, free access

‘Clinical scenario 2’ in the CCU:dyspnoea + SBP 110-150 mmHg

Decompensated chronic heart failure

• Dyspnoea develops gradually• Gradual increase in body weight• Systemic oedema• Minimal pulmonary oedema

It is a systemic illness:

• Possible renal dysfunction• Anaemia• Low albumin levels• Increased pulmonary congestion• Systemic congestion

Acute heart failure = right & left ventricular failure:results of meta-analysis

Ishihara S et al (submitted for publication)RAP - right atrial pressure PCWP - pulmonary capillary wedge pressure

LV failure

“Butterfly” pattern on chest X-ray

Monnier-Cholley L Chest X-ray in Acute Heart Failure in Mebazaa A et al (Eds) Acute Heart Failure (2009) Springer Science & Business Media

Acute heart failure = right & left ventricular failure:results of meta-analysis

RV failure

Ishihara S et al (submitted for publication)RAP - right atrial pressure PCWP - pulmonary capillary wedge pressure

Cardiorenal SyndromeType I

Ronco et al. JACC 2008, 52:1527-39

Acute setting?

?

Ronco C et al. J Am Coll Card 2008, 52:1527-39

‘abrupt worsening of cardiac function (e.g. from ADHF) leading to acute kidney injury’

Worsening Renal Function (%)CVP (p<0.01) CI

SBP PCWP

Effects of CVP, CI, SBP and PcwP on worsening renal function In Acute Heart Failure patients

Mullens et al. JACC 2009, 53:589-596

p=0.30 p=0.006

p=0.58

p=0.007

Association between baseline creatinine level and invasive haemodynamics in AHF: results of a meta-analysis

Ishihara S et al (submitted for publication)

Gheorghiade et al. Eur J Heart F 2010

Abstract of the review

« The main reason for hospitalization for acute heart failure is CONGESTION, rather than low cardiac output ».

Gheorghiade et al. Eur J Heart F 2010

Several interactions have been described in acute heart failure

- Cardio-renal syndromes

- Cardio-liver syndrome(s) ???

EFICALaboratory Tests on Admission

Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

EFICARisk Factors of 4-week Mortality

Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

Mechanical ventilation can worsen liver congestion

• 38 y.o. man, dilated cardiomyopathy• referred to the emergency room for

shortness of breath• predominant right heart failure• major hepatic cytolysis (AST: 10000 IU/l;

ALT: 5000); lactate: 5.4 mmol/L; PT 35%• Renal failure

Gatecel et al. Anesthesiology, 1995, 82:588

DANGER

Mechanical ventilation can worsen liver congestion

Gatecel et al. Anesthesiology, 1995, 82:588

Outflow pressure

Arterialpressure

Intra-tissular pressure = 0

Effect of HeartFailure

on Organ Congestion

Stable CHF

MAP > Tissular pressure

Normal

AHF

MAP < Tissular pressure

ARVF

PA

Liver/KidneyCONGESTION

RV

volume loading

RAPTR

± high PAP

Liver dysfunction in AHF:Clinical characteristics

Alk Phosphatase

normal abnormal

Transaminases

normal abnormal(37%)(22%)

Nikolaou et al Eur Heart Journal 2013

6-month mortality as a function of liver cytolysis


6-month mortality as a function of cholestatis


Normalliver lobule

bile ductcompression(increased AP)

and cytolysis(increased transaminanses)

AHF-induced liver congestion(increased BNP)

bile ductcompression(increased AP)

+++++

+ +++++



Factors associated with elevated alkaline phosphatase

Mebazaa et al Intensive Care Medicine 2011

inotropes

ALARM-HF: IV treatment at admission

0 5 10 15 20 25 30

0.0

0.1

0.2

0.3

0.4

0.5

0.6

Days

In-hos

pital m

ortality

Whole cohort

DopamineDobutamine

Epinephrine

Norepinephrine

Levosimendan

Diuretics

Vasodilatators

HFA/EUSEM/SAEM Eur Heart Journal 2015

Online, free access

What to do in the first 30-60 min (1)


What to do in the first 30-60 min (1)

SEVERITY SCORE


Next 120 min


Admission/ discharge


Main messages (1)

•Congestion is the main disease in acute heart failure

•Novel therapies, such as novel vasodilators, aim at reducing congestion

•« time is muscle «

Main messages (2)

•There are evidence for a cardio-liver syndrome in AHF

•Cholestasis is associated with signs of congestion

•Hepatolysis is associated with decreased blood flow

In summary

• There are evidence for a cardio-liver syndrome in AHF

• Cholestasis is associated with signs of congestion

• Hepatolysis is associated with decreased blood flow

cardio-hepatic syndrome organ dysfunction in acute heart ......nikolaou et al eur heart journal 2013...

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