Acute Cardiogenic liver injury is rare ,but carry a bad prognosis ,here are two interesting cases.

1. Acute Cardiogenic Liver Injury in Acute
Ischemic Heart Failure Syndromes
Dr Asadullah Soomro
Adult cardiologist
King Abdullah Medical City Holly Makkah Kingdom of Saudi Arabia.
Email; hssbasadsoomro@gmail.com

2. When The Heart Kills The Liver
Cardio –Hepatic Syndromes

3. MALIGNANT Acute
HEART FAILURE
SYNDROMES
With severe Systolic
Dysfunction
Device Related
Massive Hemolysis
Left Main Occlusion
or Severe 3VD
With Multiple Co-morbidities
MI ,Mechanical
Complications.
Massive
Rhabdomyolysis
Cardiac Tamponade
Cardio-renal
Syndrome
Cardio-embolic
stroke
Sepsis Syndrome
Device Related Infection.
Severe
hyponatremia
Acute Abdomen
Acute massive
Bleeding & Retro-peritoneal Hematoma
Critical Limb
Ischemia
Acute Cardiogenic
Hypoxic Hepatitis
Cardiogenic
Shock
Acute Pulmonary
Embolism.
Refractory Ventricular
Dysrrhythmias
And High grade AV block
Any Patient with Acute Heart Failure Syndromes , with following complex features ,who die during index hospitalization in hours to days ,may be regarded as
Malignant Heart Failure syndrome.
( Asad Soomro : hssbasadsoomro@gmail.com)

4. SOOMRO,S , CLASSIFICATION OF
ISCHEMIC HEART FAILURE SYNDROMES
ISCHEMIC
HEART FAILURE
WITH MYOCARDIAL
INFARCTION.
4
3 ISCHEMIC
HEART FAILURE
WITHOUT MYOCARDIAL
INFARCTION.
Subjective & objective evidence of healed (
Old ) myocardial infarction, complicated by
first time or recurrent heart failure
hospitalization.
2
Subjective & objective evidence of
acute myocardial infarction,
complicated by heart failure during
index hospitalization.
1
Primary symptoms of heart failure,
without symptoms of angina and
myocardial infarction ( Neither objective
evidence of MI ).
Concomitent symptoms of angina and
heart failure, without subjective or
objective evidence of myocardial
infarction.

5. Executive Summary Case 1
34year saudi male diabetic 10 years non compliant & smoker
admitted through ER with acute inferior wall STEMI and RV
extension.
Considered late for revascularization.
Complicated by by cardiogenic shock, De-novo Heart failure
and complex ventricular septal rupture.
Intubated & Ventilated at Ayoun hospital .
Further complicated by acute cardiogenic renal injury and
cardiogenic hypoxic hepatitis. No Intervention
was done ,treated with ionotropic support and expired with in 24
hours of admission.

6. Clinical Summary at Primary Hospital
First time admitted at secondary care hospital at 4 pm on 22nd May 2016 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,14
Glucose 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.

7. 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 .

8. Liver Function results 100014666
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
Albumin

9. 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
HDL 0.6
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

12. Echocardiogram
Patient tachycardia, 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.

18. Executive Summary case 2 (100025044)
57 year saudi male DM 20 years, HTN PAD ( DM foot left 2nd and 5th
big toe amputated) & CKD
Presented to ER on 9.10.2016 at 3 pm with vomiting and
breathlessness no chest pain.
EKG showed ST elevation inferior wall MI with RV extension, new
RBBB & ist degree AV block.
Complicated by cardiogenic shock and severe metabolic acidosis.
Shifted to cath lab, CAG showed 3 VD CAD ( LAD small diffusely
diseased, LCX mid 70-80% ,RCA was proximally totally occluded) .
Primary PCI done to RCA with DES and DEB to LCX.

19. Cont,
Echocardiogram showed severe LV systolic
dysfunction EF < 20%.
16x23 LV apical clot.
Next day develop malignant heart failure intubated &
ventilated .
On 11th renal function deteriorated with acute hypoxic hepatitis,
rhabdomyolysis and thrombocytopenia, done dialysis but remain
critical on multiple ionotropes.
On 14th october around 6 am developed Pulseless electrical activity,
CPR done but failed and expired at 6.55am.

20. CBC & Biochemistry ( 100025044)
Test 9&10.10.2016
Hb% 12.8,12.0
WBC 16.3,21.0
Platelet 56,40,21,18
INR 2.0,5.6,4.6
Glucose 13.0,8.9,7.5
BUN 13,18.4,21.8
Creatnine 95
CPK/MB 8797/1779/ 11440/1865
Na, K,Ca, Mg 129,6.1,1.9,0.8
Uric Acid 613,713
Cholesterol 2.4,1.8
Triglyceride 1.7,3.2
HDL 0.15
11& 12.10.2016 13 &14.10.2016
11.6,10.3 10.4,10.2
17.6,15.7 19.4,20.8
21,24,50,37 64,58
4.6,4.8,4.6 3.0,2.1
7.2,7.6 7.1, 8.5
24.9,35.6 24.9,
461,500 443,330,318
7048/591 7651/227,
8790/182
135,4.2, 139,4.8, 0.9
853,717,453 HbA1C, 11.5
1.6,1.1 Fibrinogen 157
2.3 D.dimer34.4

21. Liver Function results 100014666
Name of the test 9&10.10.2016 11& 12.10.2016 13 &14.10.2016
Total Bilirubin
18.0 21.0 ********
Direct Bilirubin
N/A****** ***** ********
AST ******* 12919,7495 3640,2359
ALT 8800 9303,8710 7757,3083
LDH 4969,9936 11095,8767 5756, 2366
Total protein
69.3 63.8 53.2
Albumin
N/A

22. Executive summary case 3
DIAGNOSIS
Out of Hospital Cardiac Arrest, Resuscitated
successfully.
Acute Posterior Wall myocardial Infarction,
complicated by cardiogenic shock, De-Novo
malignant heart failure syndrome with Severe
systolic dysfunction. Cardio-renal syndrome &
Acute hypoxic liver injury. 2VD CAD ,post PCI to
LAD.

23. Executive Summary
53 year Saudi male referred from Private Hospital
where he was admitted on morning of 23rd
december 2015 with H/O chest pain at 9 am ,on
the way to hospital became unconscious.
Arrived in their ER unconscious without recordable
vitals, immediately cardiopulmonary resuscitation
started, intubated & ventilated, initial rhythm was
asystole.

24. Cont,
After 6 times of CPR with multiple DC shocks for V
fib in between resuscitated successfully. EKG
showed acute myocardial infarction, remain in
cardiogenic shock on multiple iontropes
( Dopamine, Adrenaline & noradrenaline infusions)
Around 3 PM was thrombolysed with
streptokinase.
He was referred to PSCCH for intervention but was
declined by on call team.

25. Cont,
Remain critical, next day 24th december around 3pm accepted for
high risk intervention
He was in cardiogenic shock, heart failure and multi organ
failure.
CAG showed 2VD CAD and PCI was done to LAD, 2 DES deployed &
shifted back to CCU.
Post PCI Hb% dropped to 7.5gm,transfused 2 units of Rbc. Renal and
liver function deteriorated ,anuric, evaluated by nephrologist given
meropenium and vancomycin, dialysis could not be initiated because of
hypotension. All invain and expired at 5.56am on 25th december
2015,with 15 hours of index hospitalization.

26. Liver Function results
Name of the test 24.12.2015 24.12.2015 25.12.2015
Total Bilirubin 17.2 19.5 Not done
Direct Bilirubin 7.7 11.0 Not done
AST 7363 6704 8964
ALT 5499 4318 5383
LDH 10282 5073 9714
Total protein 35.9 25.4 25.4
Albumin 19 13 19

27. CBC & Biochemistry
Test ( 24& 25.12.2015) Result
Glucose 10.1,8.1
BUN 14.0, 18.3
Creatnine 473,498,553
Na 145,148
K 4.6 ,3.8
Ca 1.6, 1.5
Mg 0.5m 0.8
CPK 10686,12446
CKMB 1048, 684
Uric Acid 650,634
Cholesterol 1.9,1.3
Triglyceride 1.6,1.3
HDL 0.4,0.3
LDL 0.7, 0.4
Test ( 24 & 25.12.2015) Result
HB% 9.7, 7.5 ,12.4
Wbc 33.1, 26.0, 28.0
Platelet 166,115,97
INR & PTT 2.6,,3.4,2.2
Troponin >2000

28. Coronary Angiogram (24. 12.2015)
LM: Normal
LAD: Plaque rupture proximally, distally diffusely
diseased.
LCX: 50- 60% mid lesion
RCA: Diffuse mild to moderate long lesion. distal
PDA normal
Conclusion
2VD CAD, cardiogenic shock. PCI done to LAD