Characterizing Heart Failure With Preserved Ejection Fraction in End-Stage Liver Disease and Liver Transplant Outcomes

Won-Jung Shin; Hye-Mee Kwon; Sung-Hoon Kim; Hwa-Young Jang; Ji-Young Kim; Jae-Hwan Kim; Kyoung-Sun Kim; Young-Jin Moon; In-Gu Jun; Jun-Gol Song; Gyu-Sam Hwang

doi:10.1016/j.jacasi.2023.03.007

Characterizing Heart Failure With Preserved Ejection Fraction in End-Stage Liver Disease and Liver Transplant Outcomes

JACC Asia. 2023 May 16;3(3):506-517. doi: 10.1016/j.jacasi.2023.03.007. eCollection 2023 Jun.

Authors

Affiliation

¹ Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Abstract

Background: Heart failure with preserved ejection fraction (HFpEF) and its risk factors are increasingly recognized in patients with end-stage liver disease (ESLD).

Objectives: The aim of this study was to characterize HFpEF and identify relevant risk factors in patients with ESLD. Additionally, the prognostic impact of high-probability HFpEF on post-liver transplantation (LT) mortality was investigated.

Methods: Patients with ESLD prospectively enrolled from the Asan LT Registry between 2008 and 2019 were divided into groups with low (scores of 0 and 1), intermediate (scores of 2-4), and high (scores of 5 and 6) probability using the Heart Failure Association-PEFF diagnostic score for HFpEF. Gradient-boosted modeling in machine learning was further used to appraise the apparent importance of risk factors. Finally, post-LT all-cause mortality was followed for 12.8 years (median 5.3 years); there were 498 deaths after LT.

Results: Among the 3,244 patients, 215 belonged to the high-probability group, commonly those with advanced age, female sex, anemia, dyslipidemia, renal dysfunction, and hypertension. The highest risk factors for the high-probability group, according to gradient-boosted modeling, were female sex, anemia, hypertension, dyslipidemia, and age >65 years. Among patients with Model for End-Stage Liver Disease scores of >30, those with high, intermediate, and low probability had cumulative overall survival rates of 71.6%, 82.2%, and 88.9% at 1 year and 54.8%, 72.1%, and 88.9% at 12 years after LT (log-rank P = 0.026), respectively.

Conclusions: High-probability HFpEF was found in 6.6% of patients with ESLD with poorer long-term post-LT survival, especially those with advanced stages of liver disease. Therefore, identifying HFpEF using the Heart Failure Association-PEFF score and addressing modifiable risk factors can improve post-LT survival.

Keywords: cirrhotic cardiomyopathy; diastolic dysfunction; end-stage liver disease; heart failure with preserved ejection fraction; liver transplantation.