Left atrial echocardiography reveals hidden heart dysfunction in cirrhosis

A scoping review published in Cardiovascular Ultrasound concludes that the left atrium may be one of the most informative windows into cirrhotic cardiomyopathy, a poorly understood cardiac condition that affects people with liver cirrhosis and is frequently missed in clinical practice. Its central message is that left atrial enlargement, reduced atrial strain, and abnormal diastolic filling parameters recur across studies of cirrhotic patients, and that several of these measurements carry prognostic weight, associating with mortality, liver transplantation, and clinical deterioration.

Cirrhotic cardiomyopathy is defined as chronic cardiac dysfunction in patients with liver cirrhosis, regardless of the underlying cause of the liver disease, with mechanisms unrelated to preexisting structural heart disease. Its features include an impaired left ventricular systolic response to stress, diastolic dysfunction, and electrophysiological abnormalities. The World Congress of Gastroenterology established the first diagnostic criteria in 2005, and the Cirrhotic Cardiomyopathy Consortium updated them in 2019, drawing on advanced echocardiographic techniques such as tissue Doppler imaging and myocardial strain. The authors of the review note that the condition is often underdiagnosed because of limited awareness and the possibility of misdiagnosis, and that there is currently no established cardiac biomarker to assess cardiovascular risk and outcomes in patients with liver cirrhosis.

The review team searched Scopus, PubMed, and Web of Science using the Population, Concept, and Context framework endorsed by the Joanna Briggs Institute, and reported the work according to the PRISMA-ScR standard, with the protocol registered on the Open Science Framework. The population of interest was adult patients with liver cirrhosis, the concept was echocardiographic assessment of left atrial function, and the context was detection of cirrhotic cardiomyopathy. Prospective and retrospective observational, cohort, cross-sectional, and case-control designs were eligible, while reviews, conference proceedings, and abstracts were excluded.

The 20 included studies comprised 15 prospective investigations, including case-control, cross-sectional, cohort, follow-up, and observational designs, and five retrospective studies. The evidence base spans Asia, including China, Korea, India, and Pakistan; Europe, including Italy, Greece, Turkey, Germany, Romania, Denmark, Serbia, and Belgium; North Africa, represented by Tunisia; and beyond, a distribution the authors say enriches understanding of the clinical spectrum and regional aetiological patterns of the condition. Alcohol-related liver cirrhosis was the most frequently observed aetiology across the studies, with viral infection, nonalcoholic fatty liver disease and steatohepatitis, metabolically dysfunction-associated steatotic liver disease, cryptogenic and primary biliary cholangitis, and autoimmune causes also represented. All studies used conventional two-dimensional echocardiography with Doppler assessment, a subset applied speckle tracking echocardiography for atrial strain analysis, and selected studies used three-dimensional echocardiography for volumetric assessment.

On the structural side, left atrial diameter, volume, and volume index were the principal parameters evaluated, and left atrial enlargement emerged as a frequent finding in cirrhotic patients. Increased left atrial diameter was consistently associated with worsening liver disease severity, particularly with higher Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores, and also correlated with elevated brain natriuretic peptide levels, suggesting a link between atrial remodeling and neurohormonal activation. Skouloudi and colleagues reported higher left atrial volume index in patients with MELD scores of 15 or above, Lupu and colleagues observed greater volume index in Child-Pugh C patients, and Wiese and colleagues demonstrated that progressive cirrhosis was associated with increasing left atrial volume index over time. Three-dimensional echocardiography added prognostic information: Ozersari and colleagues found that a three-dimensional minimum left atrial volume index above 15 millilitres per square metre was associated with poorer survival, indicating incremental value over conventional measurements.

The strain data sharpen the picture. Using speckle tracking echocardiography, von Köckritz and colleagues demonstrated significantly impaired left atrial reservoir and conduit strain and strain rate in end-stage liver disease compared with controls, while Skouloudi and colleagues identified a reservoir strain below 39 percent as associated with worse survival outcomes. Notably, strain abnormalities were observed even when conventional systolic parameters such as left ventricular ejection fraction remained preserved, suggesting that strain-derived indices may detect subclinical dysfunction that volumetric and ejection-phase measures miss. The review authors caution, however, that strain analysis was not uniformly applied across the included studies, which limits comparability of this emerging evidence.

Diastolic function parameters told a partly convergent story with important discrepancies. Commonly reported abnormalities included reduced ratios of early to late mitral inflow velocity, elevated ratios of early mitral inflow velocity to mitral annular velocity, and decreased septal and lateral mitral annular velocities. Several individual findings carried prognostic weight: Wang and colleagues identified an early-to-late filling ratio of 0.8 or below as independently associated with increased mortality, and Lee and colleagues reported that an early inflow to annular velocity ratio of 10 or above was associated with reduced survival. Multiple studies identified diastolic dysfunction as an independent predictor of adverse outcomes, including mortality and post-transplant complications. Yet some studies did not demonstrate a clear prognostic impact of systolic or diastolic dysfunction in stable cirrhotic outpatients, and Mansoor and colleagues did not observe significant correlations between left atrial parameters and severity indices, findings the authors attribute to differences in patient selection and disease stage.

Heterogeneity runs through the entire evidence base and shapes how the findings should be read. Earlier studies relied on the 2005 World Congress of Gastroenterology criteria while more recent investigations incorporated the 2019 Cirrhotic Cardiomyopathy Consortium definitions, and Voet and colleagues reported a lower prevalence of diastolic dysfunction when revised criteria were applied, which partly explains the wide range of reported prevalence. The strength of correlation with MELD and Child-Turcotte-Pugh scores, the independence of prognostic associations after adjustment, and the dependence of diastolic dysfunction prevalence on the criteria applied all varied across cohorts. The review authors also emphasize that interpreting echocardiographic parameters in cirrhosis is inherently complex: hyperdynamic circulation, altered preload and afterload conditions, and fluctuations in intravascular volume may influence Doppler-derived indices, tissue Doppler velocities, volumetric indices, and strain measurements independently of intrinsic myocardial dysfunction.

These constraints are acknowledged openly by the authors. All included studies were observational and none were randomized, limiting causal inference; sample sizes varied considerably, aetiologies differed across cohorts, and follow-up durations were inconsistent. As a scoping review, the work did not perform formal assessment of study quality, risk of bias, or publication bias, and no quantitative pooling or meta-analysis was attempted. The review focused specifically on left atrial rather than ventricular parameters, and non-English articles were excluded, which the authors note may have limited comprehensiveness. Against this, they cite strict adherence to the Joanna Briggs Institute guidance and PRISMA-ScR reporting standards, dual independent screening and extraction with pilot testing of the data form, and a search strategy validated during a pilot phase.

Despite these limitations, the authors argue the findings carry clinical weight. Given the reported prevalence and prognostic significance of altered left atrial function and diastolic dysfunction, they suggest routine echocardiographic evaluation should be considered in patients with cirrhosis irrespective of apparent liver disease severity, particularly before transjugular intrahepatic portosystemic shunt insertion or liver transplantation, where underlying cardiac dysfunction may increase peri-procedural risk. They recommend incorporating speckle tracking echocardiography and three-dimensional echocardiography, and endorse the multiparametric, integrative approach emphasized in the 2025 American Society of Echocardiography guidelines rather than reliance on any single parameter. They also point to emerging evidence that strain imaging may detect subclinical myocardial dysfunction at earlier stages of chronic liver disease, including metabolically dysfunction-associated steatotic liver disease, while noting that direct evidence for SGLT2 inhibitor benefit in cirrhotic cardiomyopathy remains limited. Their conclusion is measured: left atrial assessment offers a promising approach for early detection and prognostic stratification, but translating it into standardized clinical practice requires well-designed prospective studies with contemporary, guideline-based diagnostic criteria.

Subject of Research: Echocardiographic assessment of left atrial function for detecting cirrhotic cardiomyopathy in patients with liver cirrhosis

Article Title: Assessing the left atrial function via echocardiography to detect cirrhotic cardiomyopathy in patients with liver cirrhosis – a scoping review

Article References: Poojary, M. S., Shetty, S., Samanth, J., Jeedigunta, M., Jaganathan, V., Srinivas, S., Jawanjal, M. P., Prabhu, S., Nayak, V., & Nayak, K. (2026). Assessing the left atrial function via echocardiography to detect cirrhotic cardiomyopathy in patients with liver cirrhosis – a scoping review. Cardiovascular Ultrasound, 24(1), Article 23. https://doi.org/10.1186/s12947-026-00383-5

Image Credits: AI Generated

DOI: 10.1186/s12947-026-00383-5

Keywords: cirrhotic cardiomyopathy, liver cirrhosis, left atrial function, echocardiography, speckle tracking echocardiography, left atrial strain, diastolic dysfunction, scoping review, MELD score, Child-Turcotte-Pugh, liver transplantation, prognosis