Subclinical right ventricular dysfunction in NASH does not impact post-liver transplant survival: Insights from echocardiographic strain imaging

• Strain imaging detects subclinical biventricular dysfunction after liver transplantation. • NASH is associated with reduced right ventricular strain at 1-year post-transplant. • Left ventricular ejection fraction remains preserved despite strain abnormalities. • Subclinical cardiac dysfunction does not impact 10-year post-transplant survival. • Strain imaging may improve pre-transplant cardiac risk stratification in NASH patients. Cardiovascular complications are a leading cause of morbidity following liver transplantation (LT), especially in patients with non-alcoholic steatohepatitis (NASH). We assessed changes in cardiac mechanics pre- and post-LT and evaluated the association between NASH etiology, myocardial strain, and long-term survival. We retrospectively studied 50 consecutive adult LT recipients from 2009 to 2012 at a single academic center. Of these, 27 patients had high-quality transthoracic echocardiograms before and one year after LT. We assessed electrocardiographic and echocardiographic parameters, including left ventricular (LV) ejection fraction (EF), global longitudinal strain (GLS), and right ventricular (RV) free wall strain. Associations were evaluated using t -tests, linear regression, and Kaplan-Meier survival analysis. 1 year following LT, QRS duration, mitral E velocity, tissue Doppler velocities (septal and lateral e′), and septal s′ were significantly reduced, indicating a decline in diastolic and longitudinal systolic function. LV GLS decreased from 19.2 % to 16.2 % ( p = 0.0002), and RV free wall strain declined from 20.5 % to 19.0 % ( p = 0.02). Amongst the various etiologies leading to LT, NASH was associated with significantly reduced RV free wall strain (β: -5.23 %; 95 % CI: -9.85 to -0.62), but not with other cardiac parameters or post-LT survival. No differences in 10-year survival were observed based on NASH status or baseline strain. Cardiac mechanics demonstrate a reduction in biventricular function despite a normal LV ejection fraction and RV fractional area change at 1 year following LT. NASH cirrhosis is associated with subclinical RV dysfunction, but this does not appear to affect long-term post-LT survival. Larger studies are warranted to clarify the prognostic role of myocardial strain in liver transplantation. As NASH is now a leading indication for liver LT, there is a critical need to understand its cardiovascular impact, particularly in the context of post-transplant outcomes. This study demonstrates that while NASH is associated with subclinical RV dysfunction as evaluated by strain imaging, these abnormalities do not significantly impact long-term survival following LT. These findings are important for transplant physicians and cardiologists evaluating LT candidates. Incorporating echocardiographic strain imaging into pre- and post-LT assessments could enhance cardiovascular risk stratification and enable patient-centric monitoring; however, further prospective studies in larger, diverse cohorts are warranted before widespread adoption.