Liver histopathological findings in advanced heart failure: a reappraisal of cardiac cirrhosis concept


Cardiogenic liver disease is a common yet poorly characterized complication of advanced heart failure (HF), and may impact clinical management in the setting of heart transplant evaluation. In this retrospective study, we describe clinical and histopathological features of liver injury in advanced HF, with a focus on the role of liver biopsy. Included were 45 HF patients, assessed for possible heart transplant, who underwent liver biopsy for suspected liver disease. Median duration of HF symptoms was 5 years. Most patients had stiff hepatomegaly and elevated bilirubin. Viral hepatitis (19 patients, 42.2%) was the most common cause of prior known liver disease. Sinusoidal dilatation was detected in the majority of patients (64.4%). Median necroinflammatory index was 3 and median fibrosis was 1, consistent with a small burden of histologically proven liver disease. Viral hepatitis was the only variable associated with a higher grade of necroinflammation and fibrosis. Nine of the 14 (64.3%) advanced fibrosis/cirrhosis patients had a viral hepatitis infection. Fibrosis was significantly associated with splenomegaly. The MELD score was not correlated with cardiac index. A coarse liver echo-pattern had a 29% positive and 63% negative predictive value for advanced fibrosis/cirrhosis. Severe liver disease is uncommon in patients with advanced HF in the absence of splenomegaly or primary causes of liver disease. Ultrasound data need to be carefully evaluated, as it may overstate the severity of liver disease. Liver biopsy may be needed to accurately stage liver disease before excluding patients from advanced treatment strategies.

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Advanced congestive heart failure


Alanine aminotransferase


Aspartate aminotransferase


Ventricular assist device


Lactate dehydrogenase


Alkaline phosphatase


Model for end-stage liver disease


Model for end-stage liver disease eXcluding INR


New York Heart Association


N-terminal-pro B-type natriuretic peptide


Pulmonary arterial pressure in systole


Tricuspid annular posterior systolic excursion


Histological activity index score


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Correspondence to Emanuele Durante-Mangoni.

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This work was supported by the AORN dei Colli-Monaldi Hospital, Naples, Italy. The authors have no conflict of interest to disclose.

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Durante-Mangoni, E., Parrella, A., Pafundi, P.C. et al. Liver histopathological findings in advanced heart failure: a reappraisal of cardiac cirrhosis concept. Intern Emerg Med 14, 931–940 (2019).

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  • Heart failure
  • Cardiac cirrhosis
  • Liver biopsy
  • Liver ultrasound