Cardiovascular risk assessment and predictors of cardiac decompensation after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

Table 1 Studies on predictors of cardiac decompensation in patients with cirrhosis post-transjugular intrahepatic portosystemic shunt study design data

Ref.	Year	Type	Design	Setting	Population	Sample (n)	Predictors	Outcomes	Follow up (months)
Ali et al[10]	2022	J	Retrospective cohort	Single centre (United States)	Patients with cirrhosis for TIPS	107	TTE: RA size, LV dimensions, PASP	Significant HF, mortality	3
Alla et al[40]	2021	CA	Retrospective cohort	Single centre (India)	Patients with cirrhosis for TIPS	164	TTE: RAP, EF, E/e’; HVPG; NT-proBNP; MELD; CTP	Significant HF, mortality	24
Billey et al[9]	2019	J	Prospective cohort	Single centre (France)	Patients with cirrhosis for TIPS	100	TTE: E/A > 1.5, E/e’ > 10, LAVI > 34 mL/m2, AS; BNP > 40 pg/mL; NT-proBNP > 125 pg/mL; QTc > 440 milliseconds	Significant HF	12
Filì et al[43]	2015	J	Prospective physiological	Single centre (Italy)	Patients with cirrhosis for TIPS	15	TTE: LV dimensions, IVS, LVEF, LAD, E/A, DT, PASP; RHC: PASP, mPAP, pADP, PCWP, TPG, CO, PVS, SVR; NT-proBNP; QTc > 440 milliseconds	Haemodynamic changes, significant HF	1
Laurenzano et al[39]	2024	J	Retrospective cohort	Dual centre (United States)	Patients with cirrhosis for TIPS	360	TTE: LAVI, E/e’, TR max, septal e, lateral e, LVEF; Intraprocedural RA pressure	Significant HF, hospitalisation, mortality	24
Luo et al[44]	2024	CA	Retrospective cohort	Single centre (China)	Patients with cirrhosis for TIPS	140	TTE: LVEF, E/A, LAVI, Septal e’, lateral e’, E/e’, pro-BNP	Significant HF, mortality	6
Modha et al[45]	2018	J	Retrospective case-control	Single centre (United States)	Patients with cirrhosis for TIPS	481	Age; RA pressure, portal vein pressure	Significant HF, mortality	1
Nguyen et al[47]	2022	CA	Retrospective cohort	Single centre (United States)	Patients with cirrhosis for TIPS	249	MELD-Na; PMHx: IHD, CVA/TIA, HFpEF	Significant HF	6
Schneider et al[11]	2023	J	Retrospective cohort	Single centre (Germany)	Patients with cirrhosis for TIPS	234	DD (ASE/EACVI), pathological E/A, HanDeCT algorithm	Significant HF	12
Vanderschueren et al[41]	2024	J	Retrospective cohort	Single centre (Belgium)	Patients with cirrhosis for TIPS	106	TTE: LAVI; Age; Albumin; NT-proBNP; Toulouse algorithm	Significant HF, mortality	12
Venner et al[46]	2025	J	Retrospective cohort	Single centre (Netherlands)	Patients with cirrhosis for TIPS	52	H2FPEF score, LA strain, HDF, QTc, E/e’ ratio, RWT	Significant HF	6
Debernardi Venon et al[49]	2021	J	Retrospective cohort	Single centre (Italy)	Patients with cirrhosis for TIPS	63	LV diastolic dimensions, EACI/ASE DD: LA diameter, LVEF, TAPSE, E/A ratio, e’, mPAP, CVP, NT-proBNP, PRA	LV DD incidence, TIPS response, mortality	12
Wade et al[48]	2021	CA	Retrospective cohort	Single centre (United States)	Patients with cirrhosis for TIPS	36	MELD-Na, bilirubin, INR, TTE parameters (atrial dimensions and pressures)	Significant HF	12

¹882 patients met inclusion criteria, only 48 were included in the final analysis.

J: Journal article; CA: Conference abstract; TIPS: Transjugular intrahepatic portosystemic shunt; TTE: Transthoracic echocardiography; RA: Right atrial; LV: Left ventricular; PASP: Pulmonary artery systolic pressure; RAP: Right atrial pressure; HF: Heart failure; EF: Ejection fraction; E/e’: Estimate of left ventricular filling pressures; HVPG: Hepatic venous pressure gradient; NT-proBNP: N-terminal pro-B-type natriuretic peptide; MELD: Model for end-stage liver disease; CTP: Child-Turcotte-Pugh score; E/A: Early to late mitral inflow velocity ratio; LAVI: Left atrial volume index; AS: Aortic stenosis; QTc: Corrected QT interval (> 440 milliseconds considered prolonged); IVS: Interventricular septum; LVEF: Left ventricular ejection fraction; LAD: Left atrial diameter; DT: Deceleration time; RHC: Right heart catheterisation; mPAP: Mean pulmonary artery pressure; pADP: Pulmonary artery diastolic pressure; PCWP: Pulmonary capillary wedge pressure; TPG: Transpulmonary gradient; CO: Cardiac output; PVS: Pulmonary vascular resistance; SVR: Systemic vascular resistance; MELD-Na: Model for end-stage liver disease incorporating serum sodium; PMHx: Past medical history; IHD: Ischaemic heart disease; CVA/TIA: Cerebrovascular accident/transient ischaemic attack; HFpEF: Heart failure with preserved ejection fraction; DD: Diastolic dysfunction; ASE/EACVI: American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines; HanDeCT: Diagnostic algorithm for haemodynamic decompensation post-transjugular intrahepatic portosystemic shunt; H₂FPEF: Scoring tool to predict heart failure with preserved ejection fraction; RWT: Relative wall thickness; PRA: plasma renin activity; LA strain: Measure of left atrial deformation.

Table 2 Studies on predictors of cardiac decompensation in patients with cirrhosis post-transjugular intrahepatic portosystemic shunt demographic data

Ref.	Age (median)	Sex (men %)	Creatinine (μmol/L)	1° cirrhosis aetiology	Child-Pugh A/B/C	MELD (MELD-Na)	TIPS indication	HF%	Cardiac disease
Ali et al[10]	58	66	97.3 (35.4-238.7)	Alcohol (39%)	A: 11%, B: 62%, C: 27%	15 (7-30)	Ref.A. (50%), V.B. (42%)	10	17%
Alla et al[40]	43		79.6 vs 159	Alcohol	7 ± 1.21	16 ± 5.3		22.2	66%
Billey et al[9]	69	79	89 ± 53	Alcohol (74%)	A: 25%, B: 66%, C: 9%	11.5 ± 4	Ref.A. (58%), pre-op (23%), V.B. (19%)	20	28% include AS: 10%
Filì et al[43]	54	80	79.6 vs 97.3	Viral (73.3% +)	A: 0%, B: 46%, C: 53.3%	14.3 ± 4	Ref.A. (100%)	0	Excluded
Laurenzano et al[39]	58	60		Alcohol (31%)		13.1 (9.7-16.7)	Ref.A. (39%), V.B. (33%), H.H. (12%)	8.8	Excluded
Luo et al[44]				Viral (56.4%)			V.B. (80.7%)	0	Excluded
Modha et al[45]	58	52	115 ± 94	MAFL (35.4%)	A: 20.8%, B: 66.7%, C: 12.5%	12.0 ± 4.7	Ref.A. (47.9%), V.B. (31.3%)	0.9	25.90%
Nguyen et al[47]						21 vs 17		11.7
Schneider et al[11]	59	59	100 (57.8-135.3)	Alcohol (58.1%)	A: 9.4%, B: 81.2%, C: 9.4%	12 (10-15)	Ref.A. (82.9%), V.B. (20.5%)	18	39.7% include AS: 8.2%
Vanderschueren et al[41]	63	69.8	93.73 (64.6-115)	Alcohol (72.6%)	8 (7.0-9.2)	12.3 (10.2-16.5)	Ref.A. (58.5%), V.B. (41.5%)	11.3	Yes, unclear
Venner et al[46]	64 vs 57						Ref.A. (50%), V.B. (40%), H.H. (6%)	44
Debernardi Venon et al[49]	59	79	113.2 ± 5.3	Alcohol (49%)	A: 0, B: 84%, C: 16%	13.7 ± 0.55	Ref.A. (100%)	3	Excluded
Wade et al[48]						13.5 vs 17.1		14

Ref.A.: Refractory ascites; V.B.: Variceal bleeding; H.H.: Hepatic hydrothorax; TIPS: Transjugular intrahepatic portosystemic shunt; MELD: Model for end-stage liver disease; MELD-Na: Model for end-stage liver disease incorporating serum sodium; HF: Heart failure; MAFL: Metabolic-associated fatty liver disease. Studies reporting “excluded” under cardiac disease excluded patients with pre-existing or clinically overt cardiac dysfunction from inclusion. Percentages reflect proportions within each study cohort.

Table 3 Summary of traditional risk factors, by study

Ref.	Advancing age (years)	MELD-Na	Portal vein pressure (mmHg)	QTc (millisecond)	IHD (previous history)	CVA/TIA (previous history)
Modha et al[45]	63.6 vs 57.1 (P = 0.041)1		> 25, P = 0.018
Nguyen et al[47]		21 vs 17, P = 0.037; [HR = 1.08 (1.02-1.14), P = 0.014]			HR = 3.48 (1.53-7.88), P = 0.002	HR = 4.45 (1.52-12.98), P = 0.006
Vanderschueren et al[41]	61.5 vs 67 [HR = 1.05 (1.01-1.09), P = 0.013]
Venner et al[46]	64.3 vs 57.4 [OR = 1.02 (1.01-1.03), P = 0.006]			453 vs 431 [OR = 1.03 (1.00-1.01), P = 0.01]
Wade et al[48]		13.5 vs 17.1 (P = 0.007)

¹Mean age (standard deviation), all other values for age are median (interquartile range).

MELD-Na: Model for end-stage liver disease incorporating serum sodium; QTc: Corrected QT interval (> 440 milliseconds considered prolonged); IHD: Ischaemic heart disease; CVA/TIA: Cerebrovascular accident/transient ischaemic attack; HR: Hazard ratio; OR: Odds ratio.

Table 4 Summary of significant transthoracic echocardiography findings, by study

Ref.	E/A ratio	E/e’ ratio	RA size (cm)	RA pressure (mmHg)	LAVI (mL/m²)	Smaller LA volume (mL)
Ali et al[10]			5.5 ± 4.9 [OR: 3.26 (1.22-10.16), P = 0.03]
Alla et al[40]	1.8 ± 0.9 [OR = 4.2 (3.9-12.3), P = 0.005]	13 ± 5 [OR = 5.6 (3.0-23.4), P = 0.003]		8 ± 3, OR = 5.7 (3.4-14.5), P-absent
Billey et al[9]	> 1.5 [OR = 6.2 (1.7-21.4), P < 0.001]	> 10 (OR = 6.7 (1.8-24.5), P < 0.001)			> 34 mL/m2 [OR = (1.2-13.6), P = 0.031]
Modha et al[45]				10.5 vs 6.6, P = 0.039
Schneider et al[11]	< 0.8/> 2, HR = 2.21 (1.17-4.16), P = 0.015
Venner et al[46]		11.4 vs 9.5 [OR = 1.06 (1.00-1.11), P = 0.04]
Wade et al[48]						46.5 vs 67.8 (P = 0.020)

E/A ratio: Early to late mitral inflow velocity ratio; E/e’ ratio: Mitral inflow velocity to early diastolic annular velocity ratio; RA: Right atrial; LAVI: Left atrial volume index; LA: Left atrial; HR: Hazard ratio; OR: Odds ratio.

Table 5 Summary of significant transthoracic echocardiography findings, by study (continued)

Ref.	LVESD (cm)	LVEDD (cm)	LVOT VTI (cm)	TAPSE (mm)	PASP (mmHg)	RWT
Ali et al[10]	3.2 vs 2.8 [OR = 5.43 (1.44-24.50), P = 0.02]	5.2 vs 4.6 [OR = 4.12 (1.51-13.47), P = 0.001]			≥ 31 (OR = 1.27 (1.51-13.47) P = 0.001)
Alla et al[40]			30 ± 6 [OR = 3.4 (4.0-32.4) P < 0.001]	30 ± 6 [OR = 3.4 (4.4-1.9), P = 0.01]
Venner et al[46]						0.39 vs 0.34 [OR = 1.03 (1.02-1.30), P = 0.012]

LVESD: Left ventricular end-systolic diameter; LVEDD: Left ventricular end-diastolic diameter; LVOT VTI: Left ventricular outflow tract velocity time integral; TAPSE: Tricuspid annular plane systolic excursion; PASP: Pulmonary artery systolic pressure; RWT: Relative wall thickness; OR: Odds ratio.

Table 6 Summary of significant serum markers, by study

Ref.	NT-proBNP (pg/mL)	BNP (pg/mL)	Elevated albumin (mg/dL)	Elevated PTT (seconds)	Reduced INR	Reduced bilirubin (g/dL)
Alla et al[40]	720 [OR = 4.2 (2.3-9.5), P < 0.001]1
Billey et al[9]	> 125 (610 vs 206, P = 0.005)	BNP > 40 (368 vs 86, P = 0.001)
Modha et al[45]			5.2 vs 2.9, P = 0.028	15.0 vs 13.2, P = 0.029
Vanderschueren et al[41]	540 vs 150, HR = 1.04 (1.00-1.07)2		HR = 1.10 (1.03-1.18), P = 0.009
Wade et al[48]					1.18 vs 1.40 (P = 0.007)	1.02 vs 2.05 (P = 0.022)

¹Denotes median value.

²Adjusted for 100 ng/L increments.

NT-proBNP: N-terminal pro-B-type natriuretic peptide; BNP: B-type natriuretic peptide; PTT: Partial thromboplastin time; INR: International normalised ratio HR: Hazard ratio; OR: Odds ratio.

Table 7 Summary of risk stratification tools, by study

Ref.	DD (ASE/EACVI)	DD CCC	Risk tools	Toulouse algorithm
Schneider et al[11]	HR = 2.22 (1.1-4.46), P = 0.025	HR = 1.75, (0.76-4.02), P = 0.19	HR = 2.93 (1.47-5.84), P = 0.0021	HR = 2.05, (0.89-4.70), P = 0.09
Vanderschueren et al[41]				High risk: 78%; All: P = 0.047; Ref.A. P = 0.003
Venner et al[46]			OR = 1.14 (1.05-1.23), P > 0.012

¹Diagnostic algorithm for haemodynamic decompensation post-transjugular intrahepatic portosystemic shunt algorithm.

²Heart failure with preserved ejection fraction diagnostic score.

DD (ASE/EACVI): Diastolic dysfunction as per American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines; DD CCC: Diastolic dysfunction per cirrhotic cardiomyopathy consortium criteria; HR: Hazard ratio; OR: Odds ratio.