Predictors of mortality after transjugular portosystemic shunt

Abstract

Aim: To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt (TIPS) can provide prognostic information that will enhance risk stratification of patients.

Methods: We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution. We recorded information regarding patient demographics, underlying liver disease, indication for TIPS, baseline laboratory values, hemodynamic determinations at the time of TIPS, and echocardiographic measurements both before and after TIPS. We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations. We also calculated Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) class. The following pre- and post-TIPS echocardiographic determinations were recorded: Left ventricular ejection fraction, right ventricular (RV) systolic pressure, subjective RV dilation, and subjective RV function. We recorded the following hemodynamic measurements: Right atrial (RA) pressure before and after TIPS, inferior vena cava pressure before and after TIPS, free hepatic vein pressure, portal vein pressure before and after TIPS, and hepatic venous pressure gradient (HVPG).

Results: We reviewed 418 patients with portal hypertension undergoing TIPS. RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmHg (P < 0.001), HVPG decreased by 6.8 ± 3.5 mmHg (P < 0.001). In multivariate linear regression analysis, a higher MELD score, lower platelet count, splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure (R = 0.55). Three variables predicted 3-mo mortality after TIPS in a multivariate analysis: Age, MELD score, and CTP grade C. Change in the RA pressure after TIPS predicted long-term mortality (per 1 mmHg change, HR = 1.03, 95%CI: 1.01-1.06, P < 0.012).

Conclusion: RA pressure increased immediately after TIPS particularly in patients with worse liver function, portal hypertension, emergent TIPS placement and history of splenectomy. The increase in RA pressure after TIPS was associated with increased mortality. Age, splenectomy, MELD score and CTP grade were independent predictors of long-term mortality after TIPS.

Keywords: Mortality; Outcomes; Right atrial pressure; Transjugular intrahepatic portosystemic shunt; Transjugular portosystemic shunts.

Figures

Figure 1

Survival after transjugular portosystemic shunts. Kaplan-Meier survival analysis censored by liver transplantation. Markers are shown at 3 and 12 mo.

Figure 2

Receiver operating characteristic curves for three-month mortality. We tested the variables right atrium pressure before TIPS (A) and estimated RVSP by echocardiography pre TIPS (B). RVSP: Right ventricular systolic pressure; TIPS: Transjugular portosystemic shunt; RA: Right atrium.

Figure 3

Kaplan-Meier analysis of three-month survival after transjugular portosystemic shunts. A: Stratified by RA pressure > 9 mmHg vs ≤ 9 mmHg; B: Stratified by estimated RVSP pressure > 40 mmHg vs ≤ 40 mmHg. The separation in survival curves in both panels is particularly noted during the first month. P values are provided by log-rank test. RVSP: Right ventricular systolic pressure; RA: Right atrium.