Organ dysfunction in acute heart failure:

Cardio-hepatic syndrome

Alexandre Mebazaa
Department of Anesthesia & Critical Care
University Hospitals Saint Louis – Lariboisière, Paris, France
University Paris 7; INSERM – UMR 942
 Conflict of interest

• Speaker’s bureau Alere, Edwards,

Thermofischer

• Consultant for Bayer, Cardiorentis, Novartis,

Orion, Vifor Pharma
 Online, free access

Short version: HFA/EUSEM/SAEM Eur Heart Journal 2015; Long version: Eur J Heart Failure 2015
‘Clinical scenario 2’ in the CCU:
dyspnoea + SBP 110-150 mmHg
Decompensated chronic
heart failure

• Dyspnoea develops gradually
• Gradual increase in body weight
• Systemic oedema
• Minimal pulmonary oedema
It is a systemic illness:
• Possible renal dysfunction
• Anaemia
• Low albumin levels
• Increased pulmonary congestion
• Systemic congestion
 Acute heart failure = right & left ventricular failure:
results of meta-analysis

LV
failure

RAP - right atrial pressure 
PCWP - pulmonary capillary wedge pressure Ishihara S et al (submitted for publication)
 “Butterfly” pattern on chest X-ray

Monnier-Cholley L Chest X-ray in Acute Heart Failure in Mebazaa A et al (Eds) Acute Heart Failure (2009) Springer Science & Business Media

Acute heart failure = right & left ventricular failure:
results of meta-analysis

RV failure

RAP - right atrial pressure 
PCWP - pulmonary capillary wedge pressure Ishihara S et al (submitted for publication)
 Cardiorenal Syndrome
Type I
?
Acute setting ?

‘abrupt worsening
of cardiac function
(e.g. from ADHF)
eading to acute
kidney injury’
Ronco et al. JACC
Ronco C et al. J Am Coll2008, 52:1527-39
Card 2008, 52:1527-39
Effects of CVP, CI, SBP and PcwP on worsening 
renal function In Acute Heart Failure patients 
CVP (p<0.01) CI

Worsening Renal Function (%)
SBP PCWP

Mullens et al. JACC 2009, 53:589-596

 Association between baseline creatinine level
and invasive haemodynamics in AHF: results of a meta-analysis
p=0.30 p=0.006

p=0.58

p=0.007

Ishihara S et al (submitted for publication)
Gheorghiade et al. Eur J Heart F 2010
 Abstract of the review

« The main reason for hospitalization for acute heart failure is 
CONGESTION, rather than low cardiac output ». 

Gheorghiade et al. Eur J Heart F 2010

Several interactions have been 
described in acute heart failure
 
- Cardio-renal syndromes
 
- Cardio-liver syndrome(s) ???
 EFICA
Laboratory Tests on Admission

Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

 EFICA
Risk Factors of 4-week Mortality

Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

DANGER Mechanical ventilation can
worsen liver congestion

• 38 y.o. man, dilated cardiomyopathy

• referred to the emergency room for
shortness of breath
• predominant right heart failure
• major hepatic cytolysis (AST: 10000 IU/l;
ALT: 5000); lactate: 5.4 mmol/L; PT 35%
• Renal failure
Gatecel et al. Anesthesiology, 1995, 82:588
Mechanical ventilation can worsen liver congestion

Gatecel et al. Anesthesiology, 1995, 82:588

Mechanical ventilation can worsen liver congestion

Gatecel et al. Anesthesiology, 1995, 82:588

 Arterial
pressure

Normal Intra-tissular pressure = 0

Outflow pressure
Effect of Heart
MAP > Tissular pressure  Failure
Stable  on Organ 
CHF
Congestion
MAP < Tissular pressure 

AHF
 ± high PAP
volume loading
PA

RAP ARVF
TR
RV

Liver/Kidney
CONGESTION
Liver dysfunction in AHF:
Clinical characteristics
Alk Phosphatase Transaminases

normal abnormal normal abnormal

(22%) (37%)

Nikolaou et al Eur Heart Journal 2013

6-month mortality as a function of liver
cytolysis

Nikolaou et al Eur Heart Journal 2013

6-month mortality as a function of
cholestatis

Nikolaou et al Eur Heart Journal 2013

 AHF-induced liver congestion
(increased BNP)

Normal bile duct bile duct

liver lobule compression compression
(increased AP) (increased AP)

+ +
+ +++ +++
+ +

and cytolysis
(increased transaminanses)

Nikolaou et al Eur Heart Journal 2013

 AHF-induced liver congestion
(increased BNP)

Normal bile duct bile duct

liver lobule compression compression
(increased AP) (increased AP)

+ +
+ +++ +++
+ +

and cytolysis
(increased transaminanses)

Nikolaou et al Eur Heart Journal 2013

 Factors associated with 
elevated alkaline phosphatase

Nikolaou et al Eur Heart Journal 2013

ALARM-HF: IV treatment at admission

inotropes

Mebazaa et al Intensive Care Medicine 2011

 0.6
In-hospital mortality

Epinephrine
0.5

Norepinephrine
0.4
0.3

Dopamine
Dobutamine
0.2

Whole cohort
0.1

Diuretics
Levosimendan
0.0

Vasodilatators
0 5 10 15 20 25 30
Days
 Online, free access

HFA/EUSEM/SAEM Eur Heart Journal 2015

What to do in the first 30-60 min (1)

HFA/EUSEM/SAEM Eur Heart Journal 2015

What to do in the first 30-60 min (1)

SEVERITY SCORE

HFA/EUSEM/SAEM Eur Heart Journal 2015

Next 120 min

HFA/EUSEM/SAEM Eur Heart Journal 2015

Admission/ discharge

HFA/EUSEM/SAEM Eur Heart Journal 2015

 Main messages (1)

• Congestion is the main disease in acute heart failure

• Novel therapies, such as novel vasodilators, aim at 
reducing congestion

• « time is muscle « 
 Main messages (2)

• There are evidence for a cardio-liver syndrome in 
AHF

• Cholestasis is associated with signs of congestion

• Hepatolysis is associated with decreased blood flow
 In summary
• There are evidence for a cardio-liver 
syndrome in AHF

• Cholestasis is associated with signs of 
congestion

• Hepatolysis is associated with decreased 
blood flow