Transjugular intrahepatic portosystemic shunt: impact on systemic hemodynamics and renal and cardiac function in patients with cirrhosis

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) alleviates portal hypertension and possibly increases central blood volume (CBV). Moreover, renal function often improves; however, its effects on cardiac function are unclear. The aims of our study were to examine the effects of TIPS on hemodynamics and renal and cardiac function in patients with cirrhosis. In 25 cirrhotic patients, we analyzed systemic, cardiac, and splanchnic hemodynamics by catheterization of the liver veins and right heart chambers before and 1 wk after TIPS. Additionally, we measured renal and cardiac markers and performed advanced echocardiography before, 1 wk after, and 4 mo after TIPS. CBV increased significantly after TIPS (+4.6%, P < 0.05). Cardiac output (CO) increased (+15.3%, P < 0.005) due to an increase in stroke volume (SV) (+11.1%, P < 0.005), whereas heart rate (HR) was initially unchanged. Cardiopulmonary pressures increased after TIPS, whereas copeptin, a marker of vasopressin, decreased (-18%, P < 0.005) and proatrial natriuretic peptide increased (+52%, P < 0.0005) 1 wk after TIPS and returned to baseline 4 mo after TIPS. Plasma neutrophil gelatinase-associated lipocalin, renin, aldosterone, and serum creatinine decreased after TIPS (-36%, P < 0.005; -65%, P < 0.05; -90%, P < 0.005; and -13%, P < 0.005, respectively). Echocardiography revealed subtle changes in cardiac function after TIPS, although these were within the normal range. TIPS increases CBV by increasing CO and SV, whereas HR is initially unaltered. These results indicate an inability to increase the heart rate in response to a hemodynamic challenge that only partially increases CBV after TIPS. These changes, however, are sufficient for improving renal function. NEW & NOTEWORTHY For the first time, we have combined advanced techniques to study the integrated effects of transjugular intrahepatic portosystemic shunt (TIPS) in cirrhosis. We showed that TIPS increases central blood volume (CBV) through improved cardiac inotropy. Advanced echocardiography demonstrated that myocardial function was unaffected by the dramatic increase in preload after TIPS. Finally, renal function improved due to the increase in CBV. Recognition of these physiological changes significantly contributes to our clinical understanding of TIPS.

Left Ventricular Longitudinal Contractility Predicts Acute‐on‐Chronic Liver Failure Development and Mortality After Transjugular Intrahepatic Portosystemic Shunt

“…As already mentioned, LV contractility appears to be decreased in patients with cirrhosis, whereas the lack of response of LV contractility to hemodynamic changes might be the reason for development of ascites and decompensation . In one elaborate, invasive, pathophysiologic, but small study in patients with TIPS, profound changes were induced in cardiac contractility after TIPS, which could only be reflected noninvasively by speckle tracking . Our present study confirms that the most suitable, noninvasive, and less biased technique seems to be STE, while it describes for the first time LV‐GLS as the best predictor of ACLF development and mortality.…”

“…Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) induces a prompt decompression of the portal venous system and effectively treats complications of portal hypertension; however, careful selection of patients is required . TIPS insertion increases central blood volume despite a severe aggravation of preload . These changes increase cardiac workload and encroach on cardiac reserves, which are especially decreased in patients with decompensated cirrhosis .…”

“…Two‐dimensional speckle tracking echocardiography (STE) is an objective surrogate of cardiac contractility . Left ventricular global longitudinal strain (LV‐GLS) is associated with outcome in patients with cirrhosis . In the present study, we evaluated for the first time the prognostic value of LV‐GLS for the development of ACLF and mortality in patients with cirrhosis treated with TIPS.…”

Does Transjugular Intrahepatic Portosystemic Shunt Stent Differentially Improve Survival in a Subset of Cirrhotic Patients?

“…65 The fre-quently used ejection fraction in resting does not identify patients who might fail after TIPS. 65 Recently, two published pathophysiological prospective studies 66,67 in humans by the group of S. Møller and F. Bendtsen demonstrated an increase in cardiac output in TIPS as well as an increase in stroke volume to increase the central blood volume. However, the authors also found an inability to increase the heart rate in response to a hemodynamic challenge after TIPS.…”

Hepatorenal Syndrome or Hepatocardiorenal Syndrome: Revisiting Basic Concepts in View of Emerging Data

“…There is avid evidence on the salutary impact of TIPS on renal function, including improved urinary sodium excretion (indicative of ameliorated renal perfusion) as well as an increase in clearance of creatinine [22]. Based on recent data, cardiorenal interplay is the key mediator of the beneficial renal effects of TIPS, as it significantly enhances cardiac inotropy, leading to increased central blood volume and renal perfusion [23]. Furthermore, the benefits of TIPS could partly be explained by improvement in endothelial function that follows mitigation of systemic inflammation through lowering pressures and shear stress in the portal system and hindering of the intestinal translocation of bacteria.…”