Biventricular systolic function and myocardial deformation in liver cirrhosis: a systematic review and meta-analysis of speckle-tracking echocardiography and cardiac magnetic resonance feature tracking studies

Background: Liver cirrhosis is frequently associated with cardiovascular abnormalities collectively referred to as cirrhotic cardiomyopathy, characterized by impaired cardiac reserve and subclinical myocardial dysfunction despite preserved conventional systolic function. Advanced myocardial deformation imaging techniques, including two-dimensional speckle-tracking echocardiography (2D-STE) and cardiac magnetic resonance feature tracking (CMR-FT), may allow earlier detection of subtle ventricular impairment. We performed a systematic review and meta-analysis to comprehensively evaluate conventional and deformation-derived indices of biventricular systolic function in cirrhotic patients. Methods: PubMed, Scopus, and EMBASE databases were systematically searched for observational studies evaluating myocardial systolic function in adult cirrhotic patients using 2D-STE and/or CMR-FT. Comparative meta-analyses between cirrhotic patients and controls were performed using standardized mean differences (SMDs) with 95% confidence intervals (CIs). Separate analyses were conducted for left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LV-GLS), left ventricular global circumferential strain (LV-GCS), left ventricular global radial strain (LV-GRS), right ventricular ejection fraction (RVEF), and right ventricular global longitudinal strain (RV-GLS). Weighted pooled descriptive analyses of clinical, laboratory, echocardiographic, and CMR findings were additionally performed. Results: Twenty studies including 1553 cirrhotic patients and 498 controls were included, whereas 14 studies were eligible for quantitative meta-analysis. Conventional LVEF remained globally preserved and showed no significant overall difference between cirrhotic patients and controls, although CMR-based studies demonstrated mildly higher LVEF values in cirrhosis. Meta-analysis revealed no significant overall differences in LV-GLS, LV-GCS, LV-GRS, or RVEF, whereas RV-GLS was significantly reduced in cirrhotic patients. Substantial heterogeneity was observed across most deformation analyses. Meta-regression demonstrated significant associations between LV-GLS variability and age, body mass index, MELD score, diabetes prevalence, heart rate, systolic blood pressure, and software vendor. Descriptive pooled analyses demonstrated larger cardiac chamber dimensions, increased filling pressures, mildly increased pulmonary pressures, and increased extracellular volume fraction values in cirrhotic populations. Conclusions: Patients with liver cirrhosis exhibit preserved conventional systolic function despite evidence of subtle myocardial mechanical abnormalities, particularly involving right ventricular longitudinal mechanics and diastolic function. Advanced deformation imaging with 2D-STE and CMR-FT may improve early detection of subclinical cardiac involvement in cirrhotic cardiomyopathy.