St. Louis University School of Medicine St. Louis, MO, United States
Francis Gerald Wade, MD1, Debapria Das, MD2, Yixi Tu, MD1, Sierra Dickey, DO2, Julien Feghaly, MD, MPH3, Philip Mar, PharmD, MD2, Kamran Qureshi, MD1 1St. Louis University School of Medicine, St. Louis, MO; 2St. Louis University, St. Louis, MO; 3University of Florida, Jacksonville, Jacksonville, FL
Introduction: Cirrhotic cardiomyopathy is a form of chronic cardiac dysfunction that is seen in cirrhotic patients due to impaired contractile responsiveness, electrophysiologic abnormalities, and/or impaired diastolic relaxation. Transjugular intrahepatic portosystemic shunt (TIPS) causes a large shift of blood flow from splanchnic to systemic circulation which can predispose to post-TIPS heart failure (HF). The purpose of this study is to identify pre- and post-TIPS echocardiogram parameters associated with greater risk of post-TIPS HF.
Methods: We performed a retrospective chart review of 36 patients who underwent TIPS at our institution between 8/2012 and 12/2019. HF was defined clinically as exhibiting signs and symptoms of volume overload including pulmonary and/or peripheral edema, dyspnea on exertion, orthopnea, and subsequent improvement with diuresis. Two tailed T-test was used for statistical analysis.
Results: Five out of the 36 patients in our study developed HF post-TIPS. In those that developed HF after TIPS, the baseline pre-TIPS INR and bilirubin were significantly lower compared to those who did not develop HF. Significant differences were noted in echocardiogram parameters in those who developed HF versus those who did not (Table 1).
Discussion: In this cohort, patients who developed post-TIPS heart failure had lower MELD, bilirubin, and INR. We theorize that increased duration and severity of systemic vasodilation in patients with more advanced cirrhosis leads to cardiac conditioning that improves tolerance of shunting blood flow from splanchnic circulation back to the systemic circulation post TIPS. This theory is further strengthened by our finding that patients who did not develop HF within one year had increased pre-TIPS cardiac output and venous return as evidenced by greater LVOT volume time interval, greater right ventricular outflow tract volume time interval, and increased left atrium volume. Hepatologists in collaboration with cardiologists may consider utilizing pre-TIPS echocardiogram parameters to help predict post-TIPS heart failure risk.
No HF (n=31)
Developed HF (n=5)
Pre-TIPS Bilirubin (gm/dL) (p=0.022)
2.05 +/- 1.11 (n=21)
1.02 +/- 0.55 (n=4)
Pre-TIPS INR (p=0.007)
1.40 +/- 0.01 (n=21)
1.18 +/- 0.96 (n=4)
Discharge MELD Na(p=0.013)
17.13 +/- 2.85 (n=15)
13.5 +/- 1.73 (n=4)
Pre-TIPS LVOT VTI (cm)(p=0.022)
26.00 +/- 5.32 (n=23)
22.73 +/- 1.16 (n=3)
Pre-TIPS LVOT Stroke Volume (cm³)(p=0.003)
88.38 +/- 21.43 (n=16)
69.75 +/- 0.35 (n=2)
Pre-TIPS Left Atrial Volume (ml) (p=0.020)
67.76 +/- 26.94 (n=27)
46.50 +/- 8.87 (n=3)
Pre-TIPS RVOT Peak Gradient (mmHg)(p=0.015)
3.07 +/- 1.20 (n=12)
1.65 +/- 0.35 (n=2)
Pre-TIPS RVOT Mean Velocity (p=0.006)
56.62 +/- 11.06 (n=7)
37.65 +/- 3.18 (n=2)
Pre-TIPS RVOT Mean Gradient (mmHg)(p=0.005)
1.47 +/- 0.61 (n=11)
0.70 +/- 0.14 (n=2)
Pre-TIPS RVOT VTI (cm)(p=0.000)
17.92 +/- 2.59 (n=9)
10.50 +/- 0.42 (n=2)
Post-TIPS Echo Days(p=0.049)
274.06 +/- 297.46 (n=31)
121.60 +/- 107.34 (n=5)
Post-TIPS LVOT Cardiac Output (cm³/min) (p=0.003)
6054.08 +/- 1140.71 (n=5)
9277.15 +/- 66.68 (n=2)
Post-TIPS LVOT Cardiac Index (cm³/min·m²)(p=0.034)
2965.65 +/- 386.66 (n=4)
4573.85 +/- 376.39 (n=2)
Post-TIPS RA Pressure (mmHg)(p=0.051)
4.00 +/- 2.14 (n=11)
8.33 +/- 5.77 (n=3)
Post-TIPS RVSP (mmHg) (p=0.041)
33.69 +/- 5.62 (n=7)
58.36 +/- 27.78 (n=3)
Table: Differences in Patients that Developed HF within 1 year (T-test, two-tailed)
HF: heart failure; TIPS: transjugular intrahepatic portosystemic shunt; LVOT: left ventricular outflow tract; VTI: velocity time interval; RVOT: right ventricular outflow tract; RA: right atrium; RVSP: right ventricular systolic pressure
Disclosures:
Francis Gerald Wade indicated no relevant financial relationships.
Debapria Das indicated no relevant financial relationships.
Yixi Tu indicated no relevant financial relationships.
Sierra Dickey indicated no relevant financial relationships.
Julien Feghaly indicated no relevant financial relationships.
Philip Mar indicated no relevant financial relationships.
Kamran Qureshi indicated no relevant financial relationships.
Francis Gerald Wade, MD1, Debapria Das, MD2, Yixi Tu, MD1, Sierra Dickey, DO2, Julien Feghaly, MD, MPH3, Philip Mar, PharmD, MD2, Kamran Qureshi, MD1. P1801 - Pre- and Post-TIPS Echocardiogram Parameters Associated With Development of Heart Failure Within One Year After TIPS, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
