Valerio Giannelli1, Olivier Roux1, Cédric Laouénan2, Pauline Manchon3, Floriane Ausloos1, Delphine Bachelet3, Pierre-Emmanuel Rautou4, Emmanuel Weiss5, Richard Moreau6, Alexandre Mebazaa7, Alain Cohen-Solal8, François Durand4, Claire Francoz9. 1. Hépatologie et réanimation hépato-digestive, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France. 2. Département d'Epidémiologie Biostatistique et Recherche Clinique, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM CIC-EC 1425, Centre d'Investigation Clinique, AP-HP, Hôpital Bichat, Paris, France; Université Paris Diderot, Paris, France. 3. Département d'Epidémiologie Biostatistique et Recherche Clinique, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM CIC-EC 1425, Centre d'Investigation Clinique, AP-HP, Hôpital Bichat, Paris, France. 4. Hépatologie et réanimation hépato-digestive, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Université Paris Diderot, Paris, France; INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France. 5. INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France; Service d'Anesthésie-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Paris, France. 6. Hépatologie et réanimation hépato-digestive, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France. 7. Service d'Anesthésie-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Paris, France; INSERM U942, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France. 8. INSERM U942, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France; Service de Cardiologie, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France. 9. Hépatologie et réanimation hépato-digestive, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France. Electronic address: claire.francoz@bjn.aphp.fr.
Abstract
BACKGROUND & AIMS: Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs. METHODS: This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis. RESULTS: LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1 g-m/m2. In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p = 0.0083) and treatment by NSBBs with LVSWI <64.1 g-m/m2 (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p = 0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score. CONCLUSIONS: This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhotic patients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis. LAY SUMMARY: There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhotic patients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.
BACKGROUND & AIMS: Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs. METHODS: This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis. RESULTS: LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1 g-m/m2. In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p = 0.0083) and treatment by NSBBs with LVSWI <64.1 g-m/m2 (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p = 0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score. CONCLUSIONS: This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhoticpatients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis. LAY SUMMARY: There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhoticpatients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.
Authors: Nikolaus Pfisterer; Caroline Schmidbauer; Florian Riedl; Andreas Maieron; Vanessa Stadlbauer; Barbara Hennlich; Remy Schwarzer; Andreas Puespoek; Theresa Bucsics; Maria Effenberger; Simona Bota; Michael Gschwantler; Markus Peck-Radosavljevic; Mattias Mandorfer; Christian Madl; Michael Trauner; Thomas Reiberger Journal: Wien Klin Wochenschr Date: 2020-12-03 Impact factor: 1.704