Internal and Emergency Medicine

, Volume 14, Issue 6, pp 931–940 | Cite as

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

  • Emanuele Durante-MangoniEmail author
  • Antonio Parrella
  • Pia Clara Pafundi
  • Martina Vitrone
  • Enrico Ragone
  • Ilaria De Rosa
  • Cristiano Amarelli
  • Rosa Zampino


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.


Heart failure Cardiac cirrhosis Liver biopsy Liver ultrasound 



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


Compliance with ethical standards

Conflict of interest

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

Statements on human and animal rights

This article does not contain any studies involving human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual partecipants included in the study.

Supplementary material

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Supplementary material 1 (TIFF 92 kb)
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Supplementary material 2 (TIFF 106 kb)
11739_2019_2033_MOESM3_ESM.docx (22 kb)
Supplementary material 3 (DOCX 22 kb)


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Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  • Emanuele Durante-Mangoni
    • 1
    • 2
    Email author
  • Antonio Parrella
    • 1
  • Pia Clara Pafundi
    • 1
  • Martina Vitrone
    • 1
  • Enrico Ragone
    • 2
  • Ilaria De Rosa
    • 3
  • Cristiano Amarelli
    • 4
  • Rosa Zampino
    • 1
    • 2
  1. 1.Internal MedicineUniversity of Campania ‘L. Vanvitelli’NaplesItaly
  2. 2.Unit of Infectious and Transplant MedicineAORN Ospedali dei Colli-Monaldi HospitalNaplesItaly
  3. 3.Unit of PathologyAORN Ospedali dei Colli-Monaldi HospitalNaplesItaly
  4. 4.Unit of Cardiac Surgery and TransplantsAORN Ospedali dei Colli-Monaldi HospitalNaplesItaly

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