Cirrhotic Cardiomyopathy (CCM)

1️⃣ Definition

Cirrhotic cardiomyopathy (CCM) is a chronic cardiac dysfunction seen in patients with advanced liver cirrhosis, characterized by:

• Impaired cardiac contractile response to stress
• Diastolic dysfunction
• Electrophysiological abnormalities (especially QT prolongation)
• In the absence of intrinsic heart disease

It is a functional, stress-induced cardiomyopathy that becomes clinically apparent during:

• Sepsis
• TIPS insertion
• Liver transplantation
• Major surgery
• GI bleeding

2️⃣ Why It Matters in ICU

For you (critical care focus), CCM is important because:

• Cirrhotics may appear hemodynamically stable at rest
• Under stress → acute LV failure
• Major cause of:
• Post-TIPS heart failure
• Post-liver transplant cardiovascular collapse
• Hepatorenal syndrome worsening
• Poor septic shock outcomes

3️⃣ Pathophysiology 

Cirrhosis → hyperdynamic circulation → chronic neurohormonal stimulation → myocardial remodeling.

Stepwise Mechanism

1. Hyperdynamic Circulation

• ↓ SVR (splanchnic vasodilation via NO)
• ↑ CO at rest
• ↓ Effective arterial blood volume

2. Chronic Neurohormonal Activation

• RAAS activation
• Sympathetic overactivity
• Vasopressin release

3. Myocardial Changes

• β-adrenergic receptor downregulation
• Impaired calcium signaling

4️⃣ Structural & Functional Changes

A. Systolic Dysfunction (Stress-Induced)

• EF may be normal at rest
• Blunted response to:
• Dobutamine
• Exercise
• Surgery

B. Diastolic Dysfunction (Early Finding)

• Impaired relaxation
• Increased LV stiffness
• E/A reversal
• Prolonged deceleration time

C. Electrophysiological Abnormalities

• QT prolongation (30–60% cases)
• Chronotropic incompetence
• Atrial arrhythmias
• Rare torsades

5️⃣ Diagnostic Criteria 

Updated criteria (2019 consensus):

A. Systolic Dysfunction

One of:

• EF < 50%
• Global longitudinal strain (GLS) < 18%
• Blunted contractile response to stress

B. Diastolic Dysfunction

≥ 3 of:

• E/e′ > 14
• e′ < 7 cm/s
• LA volume index > 34 mL/m²
• TR velocity > 2.8 m/s

C. Supportive Findings

• QTc prolongation
• Elevated BNP
• Elevated troponin

Why Does QT Prolongation Occur in Cirrhotic Cardiomyopathy?

 First – What Does QT Represent?

QT interval = total duration of ventricular depolarization + repolarization

• QRS → depolarization
• ST + T → repolarization
• QTc (corrected QT) normally:
• Men < 440 ms
• Women < 460 ms
• Dangerous ≥ 500 ms

QT prolongation = delayed ventricular repolarization

Repolarization depends mainly on potassium efflux currents (especially IKr and IKs).

In cirrhosis → these potassium currents are impaired → action potential duration increases → QT prolongs.

6️⃣ Clinical Presentation

Often Silent at Rest, but all these factors precipitate it therefore do screening ECHO in all these

7️⃣ Biomarkers in CCM

8️⃣ Hemodynamic Pattern

Typical cirrhotic patient:

• High CO
• Low SVR
• Low MAP
• Normal/low filling pressures

When CCM manifests:

• ↓ Cardiac output under stress
• ↑ LVEDP
• Pulmonary edema

9️⃣ CCM vs Alcoholic Cardiomyopathy

🔟 Impact During TIPS

TIPS → sudden ↑ preload → unmask latent LV dysfunction → acute pulmonary edema.

High-risk predictors before TIPS:

• Diastolic dysfunction
• Elevated BNP
• QT prolongation
• Older age

11️⃣ During Liver Transplant

Phases:

1. Pre-anhepatic – hyperdynamic
2. Anhepatic – decreased preload
3. Reperfusion – massive hemodynamic stress

CCM patients:

• Cannot augment cardiac output
• Risk of post-reperfusion syndrome
• Vasoplegia + myocardial depression

12️⃣ Management (Guideline-Oriented)

There is no specific therapy for CCM.

A. General Principles

• Treat cirrhosis
• Avoid volume overload
• Monitor QT interval
• Correct electrolytes

B. ICU Management

1️⃣ Septic Shock in Cirrhosis

• Norepinephrine = first line
• Vasopressin adjunct
• Dobutamine if low cardiac output

2️⃣ Acute LV Failure

• Loop diuretics
• Non-invasive ventilation
• Cautious vasodilators

3️⃣ Arrhythmia

• Correct K+, Mg++
• Avoid QT-prolonging drugs

13️⃣ Beta Blockers – Friend or Foe?

Non-selective beta blockers (NSBBs) like:

• Propranolol
• Carvedilol

Used for portal hypertension.

But:

• May worsen chronotropic incompetence
• Can precipitate hypotension in advanced cirrhosis

Use cautiously in refractory ascites or shock.

14️⃣ Reversibility

The only definitive treatment:

Liver Transplantation

After transplant:

• QT normalizes
• Diastolic function improves
• Systolic response improves

However:

• Severe pre-existing CCM → perioperative mortality ↑

15️⃣ Prognosis

Worse outcomes associated with:

• Elevated BNP
• QTc > 500 ms
• Severe diastolic dysfunction
• Child-Pugh C
• MELD > 25