Hemodynamic Evaluation of the Right Heart-Pulmonary Circulation Unit in Patients Candidate to Transjugular Intrahepatic Portosystemic Shunt

Abstract

In Europe, liver cirrhosis represents the fourth-most common cause of death, being responsible for 170,000 deaths and 5500 liver transplantations per year. The main driver of its decompensation is portal hypertension, whose progression radically changes the prognosis of affected patients. Transjugular intrahepatic portosystemic shunt (TIPS) is one of the main therapeutic strategies for these patients as it reverts portal hypertension, thus improving survival. However, the coexistence of portal hypertension and pulmonary hypertension or heart failure is considered a contraindication to TIPS. Nevertheless, in the latest guidelines, the definition of heart failure has not been specified. It is unclear whether the contraindication concerns the presence of clinical signs and symptoms of heart failure or hemodynamic changes in the right heart-pulmonary circulation. Moreover, data about induced right heart volume overload after TIPS and the potential development of heart failure and pulmonary hypertension is currently scanty and controversial. In this article we revise this issue in finding predictors of cardiac performance after TIPS procedure. Performing a fluid challenge during right heart catheterization might be a promising expedient to test the adaptation of the right ventricle to a sudden increase in preload in the first few months after TIPS. This test may unmask a potential cardiac inability to sustain the hemodynamic load after TIPS, allowing for a clearer definition of heart failure and, consequently, a more robust indication to TIPS.

EUS-Guided Combined Injection Therapy as a Secondary Prophylaxis of Gastric Variceal Bleeding in a Patient Contraindicated for TIPS: Case Report

“…In the current paper, the patient had absolute contraindications for TIPS [18]. BRTO was not discussed due to a lack of expertise.…”

A Comprehensive Review of Transjugular Intrahepatic Portosystemic Shunt–Related Complications

“…11,63 The recent rise in cases with nonalcoholic fatty liver disease (NAFLD) needing TIPS makes the issue of cardiac decompensation even more relevant, as these patients commonly have multiple associated comorbidities such as obesity, diabetes, hypertension, high cholesterol, and high incidence of renal and cardiac disease. 64 Studies have found a close correlation between the RAP and portal pressures > 25 mm Hg before TIPS with developing symptomatic heart failure after the procedure. 65,66 Other risk factors include the presence of previous congestive heart failure, preexisting cirrhotic cardiomyopathy (CCM), prolonged QTc interval, left atrial dilatation, an elevated pre-TIPS BNP > 40 pg/mL, and the presence of severe aortic stenosis.…”

“…11 63 The recent rise in cases with nonalcoholic fatty liver disease (NAFLD) needing TIPS makes the issue of cardiac decompensation even more relevant, as these patients commonly have multiple associated comorbidities such as obesity, diabetes, hypertension, high cholesterol, and high incidence of renal and cardiac disease. 64…”