Circulatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: Relationship with diastolic dysfunction

Filì, Daniela; Falletta, Calogero; Luca, Angelo; Baravoglia, Cesar Hernandez; Clemenza, Francesco; Miraglia, Roberto; Scardulla, Cesare; Tuzzolino, Fabio; Vizzini, Giovanni; Gridelli, Bruno; Bosch, Jaime

doi:10.1016/j.dld.2015.08.014

Cited by 26 publications

(35 citation statements)

References 38 publications

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“…Irrespective of echocardiography findings, in current clinical practice our patient who died on the day of TIPSS would have been deemed too high risk (MELD 28, significant cardio‐pulmonary morbidity, sarcopenia) and alternative interventions for their refractory ascites would have been considered (ie PleurX drain). Our observed cardiac death rate was similar to other studies, which range from 0% to 3.2%, despite these studies excluding patients with cardiovascular disease, cardiovascular risk factors and all‐cause death within <7‐30 days of TIPSS . In contrast, we elected to include patients with cardiovascular disease, associated risk factors, ongoing alcohol intake, Child‐Pugh C and early TIPSS complication (<7 days) in our study to reflect day‐to‐day clinical practice.…”

Section: Discussionsupporting

confidence: 77%

“…The role of echocardiography in all patients undergoing TIPSS remains under considerable debate, especially as some arguethat overt cardiac failure is very rarely reported in patients with cirrhosis . Indeed, only 1.7% (2/117) of our study cohort had early‐onset (<90 days) cardiac death attributed to TIPSS insertion, both of which occurred prior to the 2005 international guidelines in TIPSS .…”

Section: Discussionmentioning

confidence: 89%

“…The insertion of TIPSS is therefore particularly pertinent in these patients, as it is recognised that by shunting a significant volume of the portal circulation to the central circulation, the cardiac output and right atrial pressures increase by 50% and 100%, respectively. Whilst some argue that cardiac (in particular diastolic) dysfunction predicts worse outcomes after TIPSS, others are more sceptical as overt cardiac failure is very rarely reported . There remains a paucity of data from routine clinical practice regarding the utility of echocardiography in the pre‐assessment of TIPSS.…”

Section: Introductionmentioning

confidence: 99%

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Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent‐shunt in patients with cirrhosis

Armstrong

Gohar

Dhaliwal

et al. 2019

Aliment Pharmacol Ther

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Background: Cardiac dysfunction is frequently observed in patients with cirrhosis. There remains a paucity of data from routine clinical practice regarding the role of echocardiography in the pre-assessment of transjugular intrahepatic portosystemic stent-shunt. Aim:Our study aimed to investigate if echocardiography parameters predict outcomes after transjugular intrahepatic portosystemic stent-shunt insertion in cirrhosis. Methods: Patients who underwent echocardiography and transjugular intrahepatic portosystemic stent-shunt insertion at the liver unit (Birmingham, UK) between 1999 and 2016 were included. All echocardiography measures (including left ventricle ejection fraction; early maximal ventricular filling/late filling velocity ratio, diastolic dysfunction as per British Society of Echocardiography guidelines) were independently reviewed by a cardiologist. Predictors of 30-day and overall transplant free-survival were assessed. Results: One Hundred and Seventeen patients with cirrhosis (median age 56 years; 54% alcohol; Child-Pugh B/C 71/14.5%; Model For End-Stage Liver Disease 12) underwent transjugular intrahepatic portosystemic stent-shunt for ascites (n = 78) and variceal haemorrhage (n = 39). Thirty-day and overall transplant-free survival was 90% (n = 105) and 31% (n = 36), respectively, over a median 663 (IQR 385-2368) days follow-up. Model for End-Stage Liver Disease (P < 0.001) and Child-Pugh Score (P = 0.002) significantly predicted 30-day and overall transplant-free survival. Model for End-Stage Liver Disease ≥15 implied three-fold risk of death. Six per cent (n = 7) of patients pre-transjugular intrahepatic portosystemic stent-shunt had a history of ischaemic heart disease and 34% (n = 40) had 1 or more cardiovascular disease risk factors. Fifty per cent (n = 59) had an abnormal echocardiogram and 33% (n = 39) had grade 1-3 diastolic dysfunction. On univariate analysis none of the echocardiography measures pre-intervention were related to 30-day or overall transplant-free survival post-transjugular intrahepatic portosystemic stent-shunt. Conclusions: Ventricular, in particular diastolic dysfunction in patients with cirrhosis does not predict survival after transjugular intrahepatic portosystemic stent-shunt insertion. Model for End-Stage Liver Disease and Child-Pugh scores remain the best predictors of survival. Further prospective study is required to clarify the role of routine echocardiography prior to transjugular intrahepatic portosystemic stentshunt insertion.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 89%

Section: Introductionmentioning

confidence: 99%

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Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent‐shunt in patients with cirrhosis

Armstrong

Gohar

Dhaliwal

et al. 2019

Aliment Pharmacol Ther

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show abstract

mentioning

confidence: 99%

“…TIPS results in large‐volume blood shift from the splanchnic to the systemic circulation, leading to an increase in cardiac output and right heart pressures . The abrupt and sudden increase in right heart pressures following TIPS placement is usually transient . However, although uncommon, in some patients the development of post‐TIPS cardiac failure can be a complication that is difficult to treat and usually life‐threatening .…”

mentioning

confidence: 99%

Predicting Heart Failure After TIPS: Still More Questions Than Answers

Baiges

García‐Pagán

2019

Hepatology

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The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions

et al. 2022

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In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion. How to cite this article: Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology. 2022;00:1-19.

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Circulatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: Relationship with diastolic dysfunction

Cited by 26 publications

References 38 publications

Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent‐shunt in patients with cirrhosis

Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent‐shunt in patients with cirrhosis

Predicting Heart Failure After TIPS: Still More Questions Than Answers

The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions

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