ABSTRACT
Background: cardiovascular dysfunction in patients with liver cirrhosis has been reported by many workers. Diminished venous return due to ascites, peripheral vasodilatation, and malnutrition could interfere with myocardial performance. It has been shown that paracentesis associated with N albumin infusion is an effective and safe therapy for ascites in cirrhotic patients. It is associated with similar or lower incidence of complications than diuretic therapy and considerably shortens the duration of hospital stay. Cirrhotic cardiomyopathy is a term used to describe a constellation of features indicative of abnormal heart structure and function in patients with liver cirrhosis. Progressive cardiac dysfunction is detected in liver cirrhosis without being primary of cardiac disease
Objective: the objective of this study is to detect the changes in cardiac structure and function in response to aspiration of ascetic fluid in patients with liver cirrhosis and tense ascites
Patients and Methods: the study includes forty patients with liver cirrhosis and tense ascites. After collection of patients and exclusion of any primary cardiac or respiratory disease, paracentesis was done [2 liters daily for 5 successive days] in conjunction with IV albumin infusion [5 gm albumin for every one liter of ascetic fluid withdrawn]. They were meticulously studied by 12-leads ECG and Echocardiography before and after tapping of ascetic-fluid in the following order; [Pre-tapping: before paracentesis and Post-tapping: after paracentesis] to assess the magnitude of functional and structural changes of the heart in response to withdrawal of ascetic fluid
Results: after collection of clinical, laboratory, ECG and Echocardiographic data, comparison of the results before and after paracentesis revealed that, there's a significant lowering of heart rate [HR] in Post-tapping [post-paracentesis] with mean +/- SD [92.1 +/- 8.3 beat/min] versus [97.6 +/- 7.2 beat/min] in Pre-tapping [before paracentesis]. Significant increased systolic blood pressure after paracentesis, being [112.5 +/- 5.8 mmhg] in Pre-tapping versus [118.8 +/- 7 mmhg] in Post-tapping, with no significant change in their diastolic blood pressure. Serum Albumin level is significantly increased in Post-tapping with mean +/- SD [3.5 +/- 0.22 mg/dl] versus [2.8 +/- 0.33 mg/di] in Pre-tapping. A significant improvement of the estimated Q-Tc in Post-tapping after paraceritesis is observed with mean +/- SD [287.6 +/- 10.9 msec] in Post-tapping versus [297.5 +/- 11.1 msec] in Pre-tapping, with significant shortening of Q-Tc· after paracentesis. Echocardiographic results revealed that, there's a significant reduction of EDD in Post-tapping with mean +/- SD [46.9 +/- 2.2 mm] versus [48.4 +/- 3.0 mm] in Pre-tapping and also, reduction of ESD in Post-tapping with mean +/- SD [29.8 +/- 1.9 mm] versus [31.5 +/- 1.6 mm] in Pre-tapping. This resulted in significant elevation of both EF% and FS% with BF% of mean +/- SD [66.2 +/- 2.8 in Post-tapping versus 63.9 +/- 3.5 in Pre-tapping] and FS% [36.4 +/- 0.3 in Post-tapping versus 34.7 +/- 0.3 in Pretapping]. Right ventricular diameter is significantly reduced in Post-tapping with mean +/- SD [30.3 +/- 1.1 mm] than Pre-tapping [34.6 +/- 1.6 mm], and LA is also lesser in Post-tapping with mean +/- SD [36.9 +/- 1.4 mm] versus [39.5 +/- 1.6 mm] in Pre-tapping. In spite, no significant changes observed as regards Lv-mass, rvs and PW measures in between both groups. A significant improvement of left ventricular diastolic function after paracentesis was detected, in the form of, significant increased E-wave velocity, reduced A-wave'velocity and increased E/A ration, where, Post-tapping, Ewave was of mean +/- SD [0.93 +/- 0.13 mis] versus [0.65 +/- 0.08 mis] for Pre-tapping and A-wave was [0.62 +/- 0.07 mis] in Post-tapping versus [0.75 +/- 0.06 mis] for Pre-tapping, with resultant increased E/A ratio in Post-tapping where mean +/- SD [1.5 +/- 0.2] versus [0.86 +/- 0.11] in Pre-tapping. Also, reduction of deceleration time in Post-tapping with mean +/- SD [161.0 +/- 5.2 msec] versus [172.7 +/- 4.3 msec] in Pre-tapping. A significant lowering of pulmonary artery systolic pressure in Post-tapping is observed with mean +/- SD [40.1 +/- 3.2 mmhg] versus [45.8 +/- 4.3 mrnhg] in Pre-tapping
Conclusion: repeated 2 liters daily paracentesis with rv albumin infusion is safe and · effective treatment for tense ascites and showed improvement at both clinical and cardiac levels with no major complications. Improved clinical feature was detected in the form of decreased HR, increased systolic blood pressure. improved cardiac function was observed in the form of shortening of Q-Tc interval, improved diastolic and systolic Lv indices and a pronounced reduction of right ventricular and pulmonary artery systolic pressure. Indeed, structural improvement was detected in the form of reduction-in intracardiac chamber dimensions for Lv, LA and Rv diameters