CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 3, July/August 2023 AFRICA 179 Several congenital and acquired illnesses, including atrıal septal defect, Eisenmenger syndrome and tetrology of Fallot, as well as acquired pathologies, including acute pulmonary embolism and inferior myocardial infarction have been shown to disrupt the functioning of the RVOT.16-18,23 According to the findings of these investigations, RVOT function has a significant role in evaluating global RV function. Since the 1960s, myocardial dysfunction has been documented in people with liver cirrhosis, and CCM refers to a collection of different cardiac abnormalities associated with liver cirrhosis.1 CCM is characterised by impaired cardiac contractility, including systolic and diastolic dysfunction, a prolonged QT interval and other electromechanical abnormalities.2 A clinically latent hyperdynamic circulation of advanced cirrhosis is caused by a decreased afterload (reduced systemic vascular resistance), which may occur with physical or pharmacological stress.4,7 More cardiac output and increased cardiac effort are characteristics of a hyperdynamic circulation. In CCM, exercise causes an increase in LV end-diastolic pressure. Therefore, no increase in LVEF is anticipated due to a lack of response in terms of elevated cardiac reserve.5 Most researchon cirrhosis patients has focusedonLV function, commonly measured by tissue Doppler echocardiography.6 Yet, in these people, cardiac dysfunction is usually misdiagnosed or discovered after overt cardiac failure.8 RV dysfunction has been linked to the prognosis of cirrhosis patients, and many of these individuals exhibit RV dysfunction.9 Assessing RV and LV function in patients with cirrhosis is therefore critical.8,10 Numerous studies have shown that RV function is prognostic of cardiovascular disease.24-27 As a result, measuring RV systolic function is becoming increasingly important. Cirrhosis patients have increased right cardiac preload due to impaired liver function. Elevated hepatic venous pressures can affect RV function by increasing the preload. The RV function is more challenging to evaluate than the LV function. According to some studies, patients with cirrhosis have reduced diastolic and systolic functioning of the left ventricle.6,9,12 It has been shown that this deterioration can also be identified in the preclinical phase using modern speckle-tracking echocardiographic methods. Speckling-tracking echocardiography has been demonstrated to impair right cardiac systolic and diastolic function (in both clinical and subclinical phases) in this condition, which affects both the right and left ventricles.11,14,24-26 However, the methods utilised did not allow for capturing a snapshot to demonstrate how much the RVOT is impacted upon and how it might anticipate the severity of the condition. Conventional approaches disregard RVOT using indicators of longitudinal systolic function such as TAPSE, St, RV GLS, and RV free wall longitudinal strain (RVFW-LS). Again, area-based measures, such as FAC, have a technique that concentrates on the RV basal and apical areas, and RVOT spatial variation is not considered. Speckle-tracking echocardiography, which has recently been added to these techniques, must be installed as a separate software on echocardiography devices (it is not available on most devices), and most RV strain measurements are revealed off-label by imitating LV measurements.28-30 Furthermore, the fact that speckle-tracking echocardiography takes extensive training and expertise is one of the significant barriers to it being a method that can be carried out at every centre. It is therefore not freely available in daily use. A study by Hayabuchi, et al. showed that PAMVUT could predict RVOT function and correlate it with global right heart systolic function.17 Additionally, it was hypothesised that PAMVUT might be decreased before the parameters that describe the global RV systolic function. In another study, Acar et al. showed that the PAMVUT values correlated with TAPSE, St and FAC, the most widely accepted parameters of RV systolic function.18 We therefore assumed that PAMVUT could be correlated with traditional parameters of RV systolic function. Furthermore, the deterioration in RVOT systolic function demonstrated by PAMVUT might indicate impaired RV systolic function before global RV systolic dysfunction is evident from conventional RV systolic parameters. Limitations There are various limitations to our study. First of all, the patient cohort was relatively small. Second, because it was not a multicentre study, additional centres would need to confirm these results. Third, cardiac magnetic resonance (CMR), recognised as the gold-standard modality for the study of ventricular function, was not employed since CMR apparatus was not available at our centre. Fourth, severe HPS may impair RV function. However, the limited number of patients with severe HPS in our study could be interpreted as it not having a statistically significant effect on the results. Future studies may reveal how the combined S velocity is affected in patients with HPS. Finally, because this was a hypothetical research, new investigations will be required in the future to validate the study findings. Conclusion We found that CSV values could predict the severity of cirrhosis more precisely than traditional RV systolic function parameters. Also, we revealed that RVOT function could differentiate moderate-to-severe forms of cirrhosis from a mild form. We thank Prof Dr Seyit Ali Kayış for commenting on the statistical analysis of the study. We also thank Assoc Prof Dr Güray Can for his contribution to the diagnosis and follow up of the cirrhotic patients. References 1. Izzy M, VanWagner LB, Lin G, et al. Redefining cirrhotic cardiomyopathy for the modern era. Hepatology 2020; 71: 334–345. 2. Xanthopoulos A, Starling RC, Kitai T, et al. Heart failure and liver disease: cardiohepatic interactions. J Am Coll Cardiol: Heart Fail 2019; 7: 87–97. 3. Öz A, Çınar T, Taş E, et al. Assessment of pulmonary arterial stiffness in patients with cirrhosis: A prospective cohort study. Echocardiography 2021; 38: 57–63. 4. Spann A, Coe C, Ajayi T, et al. Cirrhotic cardiomyopathy: Appraisal of the original and revised criteria in predicting posttransplant cardiac outcomes. Liver Transplan 2022; 28: 1321–1331. 5. Al Atroush HH, Mohammed KH, Nasr FM, et al. Cardiac dysfunction in patients with end-stage liver disease, prevalence, and impact on outcome: a comparative prospective cohort study. Egypt Liver J 2022; 12: 1–11. 6. Sampaio F, Pimenta J, Bettencourt N, et al. Systolic and diastolic dysfunction in cirrhosis: a tissue‐Doppler and speckle tracking echocar-
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