We read with interest the article by Qureshi et al.,[1] 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.[2] 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[3] 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


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  • 1
    Qureshi W, Mittal C, Ahmad U, Alirhayim Z, Hassan S, Qureshi S, Khalid F. Clinical predictors of post-liver transplant new-onset heart failure. Liver Transpl 2013;19:701710.
  • 2
    Tachotti Pires LJ, Cardoso Curiati MN, Vissoci Reiche F, Silvestre OM, Mangini S, Carballo Afonso R, et al. Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) after liver transplantation—report of two cases. Transplant Proc 2012;44:24972500.
  • 3
    Albeldawi M, Aggarwal A, Madhwal S, Cywinski J, Lopez R, Eghtesad B, Zein NN. Cumulative risk of cardiovascular events after orthotopic liver transplantation. Liver Transpl 2012;18:370375.