Myocardial work echoes fail to predict outcomes in cirrhotic cardiomyopathy

A prospective study of nearly 100 patients with advanced liver cirrhosis has found that myocardial work, an emerging echocardiographic measure of cardiac function, was reduced in patients with cirrhotic cardiomyopathy but failed to predict a composite clinical outcome that included acute kidney injury, refractory ascites, cardiac failure and death. Instead, liver disease severity measured by the MELD-Na score and a diastolic filling parameter, the septal E/e’ ratio, emerged as the only independent predictors of that outcome. The findings, published in Echo Research & Practice, suggest that while myocardial work offers a load-independent window into myocardial performance in cirrhosis, it did not add diagnostic value beyond global longitudinal strain in this cohort.

Cirrhotic cardiomyopathy is a form of chronic cardiac dysfunction seen in cirrhotic patients of any aetiology in the absence of a primary cardiac cause. It is defined as systolic dysfunction and/or diastolic dysfunction and is often accompanied by electrophysiological changes. The condition remains subclinical in the vast majority of patients but can become overt during stressful situations such as liver transplantation, transjugular intrahepatic portosystemic shunt insertion and sepsis. Prior research has shown that it predisposes patients to complications of cirrhosis such as hepatorenal syndrome, particularly in conjunction with beta-blockers, and that even after successful liver transplantation it increases the risk of cardiac failure, graft dysfunction and mortality.

Myocardial work is a novel echocardiographic measure of myocardial performance that is independent of afterload. It is defined as the amount of energy required to eject and propel a given volume of blood through the vasculature and directly represents myocardial oxygen consumption. While the pressure-volume loop is an invasive and time-consuming procedure, myocardial work provides a non-invasive estimate of myocardial function that incorporates afterload, myocardial oxygen consumption and glucose metabolism, offering a more precise assessment than deformation parameters such as left ventricular ejection fraction and global longitudinal strain. It is calculated by specialised echocardiographic software that combines strain measurements with simultaneous blood pressure recordings, generating four indices: global work index, global constructive work, global wasted work and global work efficiency.

The research team, working across the hepatology units of two major tertiary hospitals in South Australia between January 2021 and August 2022, recruited decompensated cirrhotic patients with ascites and those undergoing liver transplant assessment. Of 96 patients studied, the mean age was 56 years, 58% were male and 59% of cirrhosis was related to alcohol misuse. The mean MELD-Na score was 17, indicating moderately advanced liver disease. Forty-seven patients had Child-Pugh class C cirrhosis, 41 had class B and 8 had class A. Sixteen patients were taking beta-blockers at baseline. Participants underwent transthoracic echocardiography and dobutamine stress echocardiography, with systolic and diastolic parameters, global longitudinal strain and myocardial work indices calculated at rest and during pharmacological stress.

Using the 2019 consortium criteria, the researchers diagnosed cirrhotic cardiomyopathy in 26 of the 96 patients, a prevalence of 27%. Sixteen of these patients had systolic dysfunction, defined as a left ventricular ejection fraction below 50% and/or an absolute global longitudinal strain below 18%, while 12 had diastolic dysfunction; two patients had both. Notably, all myocardial work indices except global wasted work were significantly decreased in patients with cirrhotic cardiomyopathy, with global wasted work increased, consistent with less efficient myocardial contraction. However, there was no clinical evidence of cardiac failure in any patient with echocardiographic evidence of the condition.

Dobutamine stress echocardiography was performed to assess contractile reserve, with dobutamine infused at 10, 30 and 50 micrograms per kilogram per minute, each for three minutes, targeting a heart rate of 85% of the predicted maximum. Among the 72 patients with paired strain analysis before and after stress, 54, or 75%, showed no augmentation of global longitudinal strain, suggesting impaired systolic reserve. Overall, compared with baseline, there were increases in ejection fraction at each dose stage, decreases in strain at the lowest and peak doses, decreases in constructive work and work index at the intermediate and peak doses, and increases in wasted work throughout. The lack of inotropic response carried no clinical association in this cohort.

Over a median follow-up of 365 days, 53 patients, or 55.8%, experienced the composite outcome: 28 developed hepatorenal syndrome or acute kidney injury, 41 developed refractory ascites and 16 died. No patient developed clinical evidence of heart failure. In univariate analysis, MELD-Na, troponin, resting and peak ejection fraction, resting and peak strain, resting and peak work index, peak wasted work, peak work efficiency, septal and average E/e’, left atrial volume index and maximal tricuspid regurgitation velocity were all associated with the outcome. In multivariate Cox regression, however, only higher MELD-Na and higher septal E/e’ remained independent predictors. Interestingly, patients who experienced the outcome had higher resting strain and work index values, which the authors interpret as reflecting a hyperactive myocardium and higher cardiac output state in advanced cirrhosis rather than preserved health.

The relationship between strain and liver severity proved counterintuitive. The study observed lower global longitudinal strain values in patients with less severe liver disease and vice versa, casting doubt on the 18% cut-off proposed in the updated diagnostic criteria. Strain measurements in cirrhotic patients have yielded conflicting results across the literature: earlier studies and a large meta-analysis of 802 cirrhotic patients found lower strain in cirrhosis compared with healthy controls, while more recent studies demonstrated higher strain values consistent with a hypercontractile state driven by systemic vasodilatation. The authors suggest that serial measurement with a reducing trend may be more reflective of true systolic dysfunction than any single value.

Cardiac biomarkers also fell short. Median troponin was 13.5 nanograms per millilitre and B-type natriuretic peptide was 189 picograms per millilitre, with no significant association between either biomarker and systolic dysfunction, diastolic dysfunction or a diagnosis of cirrhotic cardiomyopathy. Troponin was significantly elevated in patients who met the composite outcome, but it lost predictive value when adjusted for other parameters in multivariate analysis. Among the 16 patients who underwent liver transplantation during follow-up, 7 had echocardiographic evidence of cirrhotic cardiomyopathy, yet none experienced cardiac events in the perioperative or post-transplant period. Ten patients had paired echocardiograms 12 months after transplantation, showing significant reductions in strain and myocardial work alongside improvements in diastolic function, which the authors interpret as reversal of the hypercontractile myocardial state once systemic vasodilatation resolves.

The authors conclude that although myocardial work is a load-independent measure, in this study it did not add to the diagnosis of cirrhotic cardiomyopathy beyond global longitudinal strain, and neither myocardial work indices nor a diagnosis of the condition predicted the composite clinical outcome. They note that the study required good-quality echocardiographic images, sinus rhythm and the absence of aortic stenosis or peripheral vascular disease, and that CT coronary angiography might have detected asymptomatic coronary disease as a cause of diastolic dysfunction. Larger, multicentre, longitudinal studies are needed to establish the role of myocardial work, its correlation with cardiopulmonary exercise testing and its clinical significance in patients with liver cirrhosis.

Subject of Research: Myocardial work echocardiography in cirrhotic cardiomyopathy and its association with clinical outcomes in advanced liver cirrhosis

Article Title: Clinical significance of resting and dobutamine stress myocardial work in cirrhotic cardiomyopathy

Article References: Ramachandran, J., Pati, P. K., Mohammadi, F., Jospeh, M., Hecker, T., Chinnaratha, M. A., Gunton, J., Muller, K., Chapman, M., Woodman, R., & Wigg, A. (2026). Clinical significance of resting and dobutamine stress myocardial work in cirrhotic cardiomyopathy. Echo Research & Practice, 13(1), Article 34. https://doi.org/10.1186/s44156-026-00136-0

Image Credits: AI Generated

DOI: 10.1186/s44156-026-00136-0

Keywords: cirrhotic cardiomyopathy, myocardial work, global longitudinal strain, dobutamine stress echocardiography, liver cirrhosis, MELD-Na score, diastolic dysfunction, liver transplantation, echocardiography, cardiac biomarkers, hyperdynamic circulation, prospective cohort study