We read with interest the article by Qureshi et al., who reported that several clinical, hemodynamic, and laboratory parameters predict systolic or diastolic heart failure (HF) in the period after liver transplantation. The authors also showed that HF is a common medical problem and increases mortality in liver transplant recipients. Although the recognition of HF predictors could be clinically useful, cases of early-onset HF (≤30 days after transplantation) should be analyzed apart from cases of late-onset HF (>30 days after transplantation).
Early-onset HF directly reflects surgically related stress to the myocardium or hemodynamic changes, whereas late-onset HF is commonly associated with an increased prevalence of metabolic syndrome and coronary artery disease. In the perioperative period of noncardiac surgery, stress-related cardiomyopathy (Takotsubo cardiomyopathy) is a diagnosis that cannot be missed as a cause of systolic HF. We previously reported the occurrence of HF after liver transplantation in 2 patients who had cardiogenic shock and myocardial dysfunction. In both cases, echocardiography showed the typical aspect of Takotsubo cardiomyopathy without evidence of coronary artery disease. Early-onset HF may also be associated with conditions with decreased myocardial reserve, such as cirrhotic cardiomyopathy, in which a blunted response to stress results in HF when patients are exposed to fluid overload, cardiac-depressant drugs, or anemia.
There is growing evidence that cardiovascular risk factors and metabolic syndrome play important roles in the late follow-up of liver transplantation and account for a high prevalence of cardiovascular disease (especially late-onset HF) secondary to high blood pressure and coronary heart disease.
Because early-onset HF and late-onset HF have different etiologies and pathogenic backgrounds, they should be considered distinct groups. Thus, it is likely that clinical predictors of new-onset HF after liver transplantation are not the same for early and late forms of HF.
Odilson M. Silvestre, M.D.1
Alberto Q. Farias, M.D.2
Fernando Bacal, M.D.1
Departments of 1Cardiology and 2Gastroenterology
University of São Paulo School of Medicine
São Paulo, Brazil