Liver, Pancreas and Biliary TractCirculatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: Relationship with diastolic dysfunction

BackgroundCirrhotic cardiomyopathy may lead to heart failure in stressful circumstances, such as after transjugular intrahepatic portosystemic shunt (TIPS) placement.AimTo examine whether acute volume expansion predicts haemodynamic changes after TIPS and elicits signs of impending heart failure.MethodsWe prospectively evaluated refractory ascites patients (group A) and compensated cirrhotics (group B), who underwent echocardiography, NT-proBNP measurement, and heart catheterization before and after volume load; group A repeated measurements after TIPS.Results15 patients in group A (80% male; 54 ± 12.4 years) and 8 in group B (100% male; 56 ± 6.2 years) were enrolled. Echocardiography disclosed diastolic dysfunction in 30% and 12.5%, respectively. In group A, volume load and TIPS induced a significant increase in right atrial, mean pulmonary, capillary wedge pressure and cardiac index, and a decrease in systemic vascular resistance (respectively, 4.7 ± 2.8 vs. 9.9 ± 3.6 mmHg; 13.3 ± 3.5 vs. 21.9 ± 5.9 mmHg; 8.3 ± 3.4 vs. 15.4 ± 4.7 mmHg; 3.7 ± 0.7 vs. 4.6 ± 1 lt/min/m2; 961 ± 278 vs. 767 ± 285 dyn s cm−5; and 10.1 ± 3.3 vs. 14.2 ± 3.4 mmHg; 17.5 ± 4 vs. 25.2 ± 4.2 mmHg; 12.3 ± 4 vs. 19.3 ± 3.4 mmHg; 3.4 ± 0.8 vs. 4.5 ± 0.91 lt/min/m2; 779 ± 62 vs. 596 ± 199 dyn s cm−5, p < 0.001 for all pairs). At 24 h, cardiopulmonary pressures returned towards baseline.ConclusionsAcute volume expansion predicted haemodynamic changes immediately after TIPS. All patients had adequate haemodynamic adaptation to TIPS; none developed signs of heart failure.