The impact of right atrial pressure on outcomes in patients undergoing TIPS, an ALTA group study

Abstract

Background and Aims: Single-center studies in patients undergoing TIPS suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database. Approach and Results: Total 883 patients in ALTA multicenter TIPS database from 2010 to 2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure. Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model nonlinear relationship. Logistic regression was used to assess RAP association with secondary outcomes. Pre-TIPS RAP was independently associated with overall mortality (subdistribution HR: 1.04 per mm Hg, 95% CI, 1.01, 1.08, p=0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction, and heart failure. Pre-TIPS RAP was positively associated with model for end-stage liver disease, body mass index, Native American and Black race, and lower platelets. Conclusions: Pre-TIPS RAP is an independent risk factor for overall mortality after TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact.

Diastolic Dysfunction in Cirrhotic Cardiomyopathy: A Prospective Observational Cohort Study on Short-Term Outcomes in Cirrhotic Patients Undergoing TIPS

“…Our ndings also demonstrated that higher RAP was associated with mortality in patients undergoing TIPS, consistent with prior research. Increased RAP can elevate back pressure in the liver, be linked to heart failure, and limit TIPS e cacy in reducing the portal pressure gradient [19,20,24]. Our results also showed that the CCM group had higher MELD scores than the no-CCM group, suggesting that the severity of LVDD could serve as a sensitive marker for advanced cirrhosis and mortality, warranting increased attention in cirrhotic patients.…”

Review article: Recent advances in ascites and acute kidney injury management in cirrhosis

“…Careful cardiac assessment pre-TIPS is recommended to reduce the likelihood of cardiac decompensation post-TIPS. The incidence of heart failure post-TIPS has been quoted to be between 10% 58 to 20%, 59 with right atrial pressure 60,61 and various echocardiographic parameters 58 can be performed safely in patients 70 years and older, but with significantly higher overall readmission rates, specifically for HE. 67 The results of this preliminary study clearly need further confirmation.…”

“…Careful cardiac assessment pre‐TIPS is recommended to reduce the likelihood of cardiac decompensation post‐TIPS. The incidence of heart failure post‐TIPS has been quoted to be between 10% 58 to 20%, 59 with right atrial pressure 60,61 and various echocardiographic parameters 58 predictive of post‐TIPS heart failure development. It is advisable that all patients undergoing elective TIPS insertion to receive careful cardiac investigations before TIPS placement.…”