Hepatic Hypoperfusion in Complex Cardiac Pathology: A Case of Ischemic Hepatitis Secondary to Congenital Heart Disease with HFpEF and Atrial Fibrillation

Abstract

Ischemic hepatitis (IH) is an acute liver injury caused by hepatic hypoperfusion, typically occurring in shock states. We present a 77-year-old woman with congenital heart disease (CHD), heart failure with preserved ejection fraction (HFpEF), and atrial fibrillation who developed IH without overt hypotension. She presented with dyspnea, weakness, and oliguria, accompanied by severe transaminitis (Aspartate Aminotransferase - AST 6602 U/L, Alanine Aminotransferase - ALT 3886 U/L), coagulopathy (International Normalized Ratio - INR 7.35), and lactic acidosis (lactate 6.8 mmol/L). Echocardiography revealed atrial fibrillation with rapid ventricular response, pulmonary hypertension, and valvular abnormalities. Management included rate control, diuresis, and hepatic support. Liver enzymes improved by day 4, confirming recovery. This case demonstrates that IH can occur in HFpEF patients with CHD and arrhythmia, even in the absence of profound hypotension. Early recognition and hemodynamic optimization are critical to prevent irreversible liver damage. This case report underscores IH as a potential complication in high-risk cardiac patients, necessitating vigilant monitoring and prompt intervention.