Assessment and Reversibility of Hepatic Abnormalities in Heart Failure: Liver in Heart Failure

Hepatic abnormalities in non-Fontan heart failure result from congestive hepatopathy and hypoperfusion-related ischemic injury, compounded by neurohormonal activation and systemic inflammation. Assessment of liver disease severity is challenging because standard liver biochemistries, serum fibrosis markers, severity score models, elastography, and imaging modalities have limited diagnostic accuracy in congestive hepatopathy, and hepatic fibrosis is often heterogeneous on histology in this population. Management focuses on optimization of cardiac function through medical therapy or mechanical circulatory support. Although liver biochemical abnormalities frequently improve with restoration of cardiac function, histologic reversibility is variable and not consistently observed. In patients with advanced heart failure needing heart transplantation, histologic cirrhosis and/or fibrosis accompanied by portal hypertension may merit consideration of combined heart-liver transplantation, but correlation between fibrosis and clinical outcomes varies. There remains an unmet need for tests that can reliably assess liver disease severity and predict liver outcomes in non-Fontan congestive hepatopathy.