Cardiogenic liver injury in acute heart failure syndromes.

1. When The Heart Kills
The Liver
Acute Cardiogenic Liver Injury
In Heart Failure syndromes
Why Cardiologist is inetrested in Liver ?
Acute heart failure ( small heart ) verses Chronic HF ( big heart)
Asadullah Khan Soomro, Adult Cardiologist KAMC Holy Makkah
Email: hssbasadsoomto@gmail.com
Tiger is Small but treacherous Elephant is Huge but Pliant

3. Executive Summary
34year male diabetic 10 years , non compliant to diet and drugs, smoker indeed admitted
through ER with acute inferior wall STEMI and RV extension.
Considered late for revascularization.
Diagnosed to have acute de-novo Heart failure and complex
ventricular septal rupture. Complicated by by cardiogenic
shock
Intubated & Ventilated at local hospital .
Further complicated by acute cardiogenic renal injury and
cardiogenic hypoxic hepatitis. No Intervention was done
,treated with ionotropic support and expired with in 27 hours of
admission.

4. Clinical Summary from primary Hospital
First time admitted at secondary care hospital on 22nd May 2016 at 4 pm with
H/O dizziness.
Next day at 10 am develop breathlessness and bradycardia there fore
intubated & ventilated.
Considered DM ketoacidosis, EKG was reported to be normal,
Hb,8.9,Wbc, 14Glucose was 205mg,Bun, 23,creatnine 319,
Na,136,K5.0,Tbil,0.7,Dbil 0.4, Tprot,51.5,Alb,22, Ketones nil,
urinary Alb++,Glu,+++,Wbc,15-20,ABG metabolic acidosis, PH
6.9,7.0,HCo3,5.7.
Given normal saline 2000ml,diazepam,lasix & Ventolin. Ultrasound abdomen
showed hepatomegally, moderate ascites & pleural effusion.

5. Cont,
On 23rd Creatnine increased to 424,Bun, 29,K,6.3, Tbil,3.4,Dbil,1.5
Alb,26,Choles 169,TG,104.
Referred to KFHH ER for nephrology consultation & cardiac evaluation
for heart murmur.
EKG showed Q waves with ST elevation in inferior leads, considered
late presentation of inferior wall MI with RV extension
Bed side Echo done in ER, which showed large ventricular septal
rupture. dilated Right side. He was hypotensive evaluated by
nephrologist, and was advised CRRT .despite all available technologies
and skilled personnel yet could’nt do any thing and he expired .
“ When heart kills liver,
only option is heart and liver transplant , yet ????? “

6. Liver Function results
Name of the test 23.5.2016 24.5.2015 24.5.2015
Total Bilirubin
at Ayoun, 3.4
126.7 334.9 *****
Direct Bilirubin
at Ayoun,1.5 91.3 193.7 AlPo4, 225
AST
4682 8692 13292
ALT
3547 8413
ALT 100 times , LDH 50 times high.
( LDH :ALT ratio 1:1.4)
LDH 4784 7048 11231
Total protein
57.4 ****** 49.6

7. CBC & Biochemistry
Test 23.5.2016
Hb% 8.4,7.6
WBC 35.7
Platelet 218
INR
4.0
Glucose 9.8,12.4
BUN
33.1,33.9
Creatnine
545,588
CPK/MB 916/188
Na, K, Ca, Mg 136,6.7,1.9,0.8
Uric Acid 1130
Cholesterol 3.0
Triglyceride 2.1
24.5.2016 ( B Group, O+v )
7.5
25.6
130
17.9,5.1
33.7, 26.2
602,503
1236/149
149,7.4

8. 12 Lead EKG , Look at ST elevation in V1 ,which is rarely seen on 12 lead EKG because upper septum is protected by dual
supply from LAD and RCA. In inferior wall MI though very rare, but specific sign of RV extention before right sided leads. In
Ant wall MI indicate concomitant disease in RCA.

9. 12 lead EKG right sided

14. Echocardiogram
Patient tachycardiac, on ventilator
Normal LA/LV size, Dilated RA/RV and Impaired RV and LV
systolic function. LVEF 40-45%.
Akinetic inferior wall and basal septum. Large tear in mid -
inferior septum ( VSR) with left to right shunt PG,89mm.
Mild MR,TR, PASP= 40mm, small pericardial effusion.

15. Acute Cardiogenic liver
Injury
Executive Summary Case 2
47 year male physician no DM HTN but smoker indeed , sudden severe chest
pain at home . Out of hospital cardiac arrest ,resuscitated successfully by
physician friend .
Shifted to advanced heart center, EKG showed acute STEMI with cardiogenic
shock . ( Ischemic HF type 1) . ECMO was inserted. Severe biventricular
systolic dysfunction EF 10-15%. no mechanical complications.
Shifted to cath lab, Coronary angiogram revealed 3 VD CAD .
Anatomy was suitable for complete revascularization ,multi vessel PCI done .
Received all post resuscitation care, ionotropes, IABP, Impella, CRRT
,ventilator ,what not but expired with in 27 hours of event.
“ malignant Heart attack or heart failure ?? Combination
“ The heart kills the Liver “

16. Acute Cardiogenic liver
Injury
Executive Summary Case 2
Date Total/
Direct
Bilirubin
AST ALT LDH Total
Proteins
Albumin Creatnin Trop CPK/MB Hb Wbc/
PLT
25.11.19 04/0.2 452/611 166/347 1100 4.8 3.4 2.1/2,0 7.4 6589/
819
Ratio,12.4
7.4/5.7 13.0
177/82
26.11.19 1.2/0.5 1222/
3754
847/
2633
4.9 3.0 2.2 834 8.5 8.1
68
27.11.19 2.8/1.0 6303/ 3528/ 4.7 3.1 1.9 1409 17872/
581
8.4 17.8
35
Liver function test/Others

17. Acute Cardiogenic liver Injury
In Chronic advanced HF Syndro
Journey ( October 2010 to May 2013)
Executive Summary Case 3
34 year male , married father of one baby , no DM,HTN social smoker indeed ,I had a
honor to review him first time in HF clinic, on 7.1.2012 ,with previous background of
while studying at Saint Mary University Halifax infirmary Canada in october
2010,developed symptoms of heart failure FC 111 1V,preceded with cough flue and
fever considered and treated as Pneumonia at community health center . Later
evaluated at HF clinic and was discovered to had post myocarditis / Idiopathic
dilated cardiomyopathy with severe LV systolic dysfunction EF 20%.
Remain compensated on medical treatment until January 2012, while on vacation at
native home town. I admitted him from the clinic with acute decomensation of chronic
heart failure ( ADCHF ) ,with uncontrolled new DM ,glucose 53.9 mmol, K 6.1, creatnine
137,Na 128. ( Non ketotic hyperosmolar state),managed with insulin ,HF stablized and
travelled back to Canada to complete studies.

18. Acute Cardiogenic liver Injury
In Chronic advanced HF Syndro
Journey ( October 2010 to May 2013)
Executive Summary Case 3
In March 2013 readmitted at Halifax and After complete work up including
right heart study at heart failure and transplant center .Confirmed to
had Advanced heart failure syndrome Stage D, with severe biventricular
systolic dysfunction EF 15% ,pulmonary hyperension ( Weight 172 Kg, S3
gallop ,PSM at apex, Edema ++ mean pulm pressure 44,wedge pressure 24-
30,low systemic vascular resistance ) Had cardio-renal and chronic passive
liver congestion ( Total bilirubin 36 .4 and Direct Bilrubin 27, AST 55,ALT 29,
LDH 395, Alpo4 220 and albumin 34, creatnine 139,K 6.2 and Na 126) His case
was discussed and considered unsuitable for LVAD and transplant ,Implanted
ICD and transferred to our center through air Ambulance on 14.4.2013 at 3.04
am ,he had refractory heart failure ionotropic dependent . Remained critical
intubated and ventilated ( Wet and Cold) .Expired on 9.5.2013 at 5.35 am.

19. x rays of 33 year male with advanced heart failure,
huge elephant heart before and after ICD

20. Acute Cardiogenic liver
Injury
Executive Summary Case 3
Date Total/
Direct
Bilirubin
AST ALT LDH Total
Proteins
Albumin Creatnin Na/K CPK/MB Hb Wbc/
PLT
11.4.
2013
** *** *** *** *** *** 202/
Up to
400-500
124/
4.7
11.8 6.2/
312
Canada
14.4.13
admission
36.4/
27.4
55 29 395 71.9 34 139 126/
6.2
296/40 11.2 6.1/26
1
8.5.13 113.5/ 90 87 588 62.2 27 166 125/ 212/19 9.6 6.5/
Liver function chronic advanced HF

21. THANK YOU