From the Guidelines
Congestive hepatopathy is a condition characterized by liver damage and fibrosis resulting from chronic elevation of hepatic venous pressure due to various causes of heart failure.
Causes and Pathophysiology
- The principal causes of congestive hepatopathy include heart failure, Fontan operation, rheumatic heart disease, constrictive pericarditis, and ischemic cardiomyopathy 1.
- The pathophysiology of congestive hepatopathy involves liver congestion, hypoxia, and hepatic ischemia, leading to sinusoidal dilatation, perisinusoidal fibrosis, and eventually liver fibrosis and cirrhosis 1.
Clinical Features and Diagnosis
- The clinical features of congestive hepatopathy may include signs of liver disease, such as jaundice, ascites, and hepatic encephalopathy, as well as signs of heart failure 1.
- The diagnosis of congestive hepatopathy can be challenging, as liver stiffness measurements (LSM) may be increased due to systemic venous congestion, making it difficult to assess liver fibrosis 1.
Histological Characteristics
- The histological characteristics of congestive hepatopathy include gross architectural distortion, massive sinusoidal dilation, and perisinusoidal fibrosis in the absence of significant parenchymal inflammation 1.
- The degree of hepatic congestion and changes in cardiac function can significantly alter LSM measurements, reducing the reliability of non-invasive tests (NITs) for assessing liver fibrosis 1.
From the Research
Definition and Causes of Congestive Hepatopathy
- Congestive hepatopathy is a condition that develops in the setting of long-standing systemic venous congestion, often caused by heart failure 2, 3, 4, 5.
- It results from passive venous congestion in the setting of chronic right-sided heart failure, leading to sinusoidal hypertension, centrilobular fibrosis, and ultimately, cirrhosis and hepatocellular carcinoma 4.
- The condition can also be caused by compromised hepatic venous flow or heightened intrahepatic pressure, and is a significant consequence of cardiovascular conditions like congestive heart failure (CHF) 5.
Clinical Characteristics and Diagnosis
- Congestive hepatopathy is frequently observed in patients with congenital heart disease and after the Fontan procedure, as well as in older patients with chronic heart failure 2.
- The clinical picture and prognosis is usually dominated by the underlying heart condition, but liver disease could become as clinically relevant as cardiac disease and further complicate its management 4.
- Diagnostic challenges arise due to symptoms mirroring primary liver diseases, and management revolves around addressing the underlying cause and mitigating fluid retention 5.
Complications and Treatment
- Congestive hepatopathy can evolve into cirrhosis and hepatocellular carcinoma, and screening for liver injury should be performed in patients with chronic cardiac diseases and after Fontan surgery 2.
- Chronic liver injury can be reversible if heart function improves, but in the case of terminal heart failure, uncontrolled by medical resources or by assistive device support, the combination of heart and liver transplants must be discussed in patients with chronic advanced liver fibrosis 2.
- Treatment of congestive hepatopathy should be directed toward optimizing the cardiac substrate, and liver-related scores and ascites can improve prognostication in patients after heart transplantation 6.
Prognosis and Outcomes
- The post-heart transplantation survival was 87% and liver-related events were rare (3%) in patients with congestive hepatopathy 6.
- Severe ascites, low cholinesterase, and MELD/MELD-XI were associated with ascites persistence/death 1-year after heart transplantation, and age, male sex, and severe ascites were the only independent predictors of post-heart transplantation mortality 6.