How is right heart failure managed in patients with cirrhosis?

Management of Right Heart Failure in Patients with Cirrhosis

Right heart failure in cirrhotic patients requires aggressive hemodynamic monitoring with echocardiography, judicious fluid management using balanced crystalloids or albumin, norepinephrine as first-line vasopressor, and careful consideration of pulmonary vasodilators when portopulmonary hypertension is present, while recognizing that right ventricular dysfunction significantly impacts outcomes during TIPS and liver transplantation. 1

Initial Assessment and Monitoring

Early baseline assessment of volume status, perfusion, and cardiovascular function is essential in all critically ill cirrhotic patients. 1

• Bedside echocardiography is the cornerstone for evaluating volume status and cardiac function in cirrhotic patients with hypotension or shock. 1
• Monitor for portopulmonary hypertension (POPH), which requires close surveillance for right ventricular (RV) dysfunction, especially when conditions worsen RV afterload such as acute lung injury. 1
• Invasive hemodynamic monitoring with arterial and central venous catheters may be necessary for adequate assessment of cardiac function and titration of vasopressors and fluid resuscitation. 1

Fluid Management Strategy

Implement a judicious strategy for intravascular volume resuscitation utilizing hemodynamic monitoring tools to optimize volume status. 1

• Use balanced crystalloids (e.g., lactated Ringer's) and/or albumin for fluid administration when resuscitation is required. 1
• Avoid overtransfusion, which increases portal hypertension and variceal bleeding risk, while undertransfusion causes tissue hypoperfusion and increases multiple organ failure risk. 2
• In cirrhotic patients with tense ascites and respiratory compromise, perform timely therapeutic paracentesis to facilitate respiratory function and potentially earlier extubation in mechanically ventilated patients. 1

Vasopressor Management

Target a mean arterial pressure (MAP) of 65 mm Hg in patients with cirrhosis and septic shock, with ongoing assessment of end-organ perfusion. 1

• Norepinephrine is the first-line vasopressor for hypotension with concurrent appropriate fluid resuscitation. 1
• Vasopressin is recommended as second-line when increasing doses of norepinephrine are required. 1
• Consider screening for adrenal insufficiency or empiric hydrocortisone 50 mg IV every 6 hours (or 200 mg infusion) for 7 days or until ICU discharge for refractory shock requiring high-dose vasopressors. 1

Management of Portopulmonary Hypertension

When POPH is present, pulmonary vasodilator therapy should be considered to reduce mean pulmonary artery pressure (mPAP) to <35 mm Hg. 1

• Use inhaled nitric oxide, epoprostenol, or PAH-targeted therapy in select cases to optimize cardiopulmonary management. 1
• With mechanical ventilation, use low tidal volume and low positive end-expiratory pressure (PEEP) to minimize negative effects on RV preload and afterload. 1
• Therapy to lower mPAP and improve right ventricular function should be commenced in patients with mPAP ≥35 mm Hg, with periodic evaluation of RV function. 1
• A mPAP of ≥45 mm Hg is considered an absolute contraindication to liver transplantation irrespective of therapy applied. 1

Critical Pitfall: TIPS in Right Heart Failure

TIPS may be contraindicated or ineffective in patients with significant right heart failure, as elevated central venous pressure can negate the beneficial effects of portal decompression. 3

• Even when TIPS successfully reduces hepatic venous pressure gradient, portal pressure may remain elevated due to persisting right heart failure with elevated central venous pressure. 3
• Cardiac reserve is a major clinical consideration for elective TIPS placement, and 2D echocardiography to assess left ventricular ejection fraction is standard practice. 1, 4
• Presence of diastolic dysfunction at time of TIPS has been associated with poor survival in some studies. 1

Considerations for Liver Transplantation

Detailed functional cardiac characterization should be part of the assessment for liver transplantation. 1, 4

• If mPAP <35 mm Hg and right ventricular function is preserved, liver transplantation should be considered. 1
• Patients with higher brain natriuretic peptide (BNP) levels (>391) on day one post-transplant tend to have higher mortality and longer dialysis requirements. 1, 4
• In severe acute rises in pulmonary artery pressure, management includes IV prostacyclin or inhaled nitric oxide, with consideration of extracorporeal membrane oxygenation (ECMO) in cases of graft failure due to hepatic congestion through a failing right ventricle. 1
• Monitor pulmonary artery pressure response to therapy via serial transthoracic echo with tissue Doppler at 4-6 month intervals, with consideration of tapering pulmonary artery targeted therapy. 1

Diuretic Management

In cirrhotic patients with right heart failure and volume overload, diuretic therapy requires careful titration. 5, 6

• In patients with cirrhosis, initiate spironolactone therapy in a hospital setting and titrate slowly, with recommended initial daily dosage of 100 mg administered in single or divided doses (range 25-200 mg daily). 5
• Furosemide therapy is best initiated in the hospital for patients with hepatic cirrhosis and ascites, with strict observation during diuresis as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma. 6
• Supplemental potassium chloride and aldosterone antagonists are helpful in preventing hypokalemia and metabolic alkalosis. 6