This syndrome affects the liver and may leads to abnormally functioning of liver, and increased liver enzymes. The main cause may be due to cardiac failure. Liver function test, liver ultrasound are important to role out the liver cirrhosis

1. Dr. Alto Medical
Education
Cardio-Hepatic Syndrome
Dr. Ayub Abdulkadir Abdi
(Dr. ALTO)
• Medical Doctor
• Medical Lecturer
• Ms Tropical Medicine & Infectious
Disease
• Bachelor of Medicine and Surgery
• Medical Laboratory Technician

2. Definition:
• The combination of clinical-laboratory signs of
liver dysfunction and acute or chronic cardiac
pathology.
• Or
• Liver injury in decompensated heart failure.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 2

3. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 3

4. Etiology:
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 4

5. Pathogenesis:
1. Hypoperfusion-induced hypoxia, and Hepatic
ischemia characterized by:
• Early activation of Kupffer cells.
• Late activation of:
Polymorphonuclear cells (“neutrophilic hepatitis”).
Intracellular calcium overload.
Cytokines and chemokines.
Oxidative stress, mitochondrial damage, and disruption
of liver microcirculation.
• CENTRILOBULAR COAGULATIVE NECROSIS.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 5

6. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 6

7. Acute Cardiogenic Injury:
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 7

8. 2. Hepatic congestion due to absence of valves in
hepatic veins leads to:
Increased inferior caval pressure.
Centrilobular congestion, sinusoidal dilation, and
perivenular fibrosis.
Centrilobular liver cell necrosis.
Accumulation, deposition and spread of connective
tissue.
• Ultimately leading to CIRRHOSIS.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 8

9. Chronic Congestive Hepatopathy:
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 9

10. Morphology:
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 10

11. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 11

12. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 12

13. Criteria:
1) Setting: cardiac, circulatory, or pulmonary
failure.
2) Aminotransferase levels, usually >20 times the
upper limit of normal.
3) Exclusion of other causes of liver damage.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 13

14. Clinical Feature:
• Hepatomegaly “ enlarged liver size” and it’s
consequences including:
oPain in right hypochondrium.
oFatigue.
oNausea or lack of appetite.
oJaundice (yellowing of the skin and eyes).
oDark-colored urine and light-colored stools.
oItchy skin (pruritis).
oEnlarged spleen (splenomegaly).
oAscites.
• No development of variceal hemorrhage or
encephalopathy.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 14

15. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 15

16. Other clinical feature:
• CNS: headache, insomnia, restlessness, confusion.
• Pulmonary: pulmonary hypertension, pleural
effusion, cough, and dyspnea.
• Cardiovascular: tachypnea.
• Renal: oliguria, and nocturia.
• Peripheral edema.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 16

17. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 17

18. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 18

19. Diagnosis:
• Physical examination:
• Firm liver on physical examination.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 19

20. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 20

21. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 21

22. 06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 22

23. 2- Lab test:
a) Elevated alkaline phosphate (normal level = 44
and 147 U/L).
b) Increased aminotransferase (AST > ALT). Normal
level of AST = 8 to 33 U/L and ALT = 4 to 36 U/L
c) Elevated total bilirubin levels (normal level = 1
mg/dl).
d) Hypoalbuminemia (normal level = 3.4 to 5.4
g/dL).
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 23

24. 3- Histopathology:
• Liver biopsy shows a pattern of fibrosis.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 24

25. 4- Medical imaging:
• Ultrasound: dilated IVC and dilated hepatic veins.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 25

26. Doppler ultrasound: Hepatic vein Doppler finding
includes highly pulsatile blood flow showing a
prominent d wave, a retrograde s and a wave
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 26

27. Portal (A) and hepatic (B) vein waveforms at the time
of cardiac decompensation. Note the pulsatile portal
vein and monophasic [D is the only anterograde
wave] hepatic vein tracings
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 27

28. Portal (A) and hepatic (B) vein waveforms after
decongestive therapy. Note improved pulsatility of
the portal vein and return of the S-wave below the
baseline on the hepatic vein tracing
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 28

29. Pleural effusion:
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 29

30. Pulmonary edema:
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 30

31. Cardiomegaly
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 31

32. Treatment:
• Based on management of the underlying cardiac
disease.
• General measuremnts such as:
1. Bed rest.
2. Stop smoking.
3. Low diet sodium intake.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 32

33. • Drugs such as:
1) Diureteics.
2) Antihypertensive drugs.
3) Vasodilators.
4) Digitalis.
5) Anticoagulant.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 33

34. • Surgery:
i. Coronary revascularization.
ii. Bivantricular pacing.
iii. Implantable cardioverter defabrilization.
iv. Left ventricular assist device.
v. Heart transplantation.
06/10/2023 Cardio-Hepatic Syndrome (Dr. Alto) 34