Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 18, 2016; 8(11): 520-529
Published online Apr 18, 2016. doi: 10.4254/wjh.v8.i11.520
Predictors of mortality after transjugular portosystemic shunt
Mona Ascha, Sami Abuqayyas, Ibrahim Hanouneh, Laith Alkukhun, Mark Sands, Raed A Dweik, Adriano R Tonelli
Mona Ascha, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
Sami Abuqayyas, Laith Alkukhun, Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
Ibrahim Hanouneh, Minnesota Gastroenterology, Minneapolis, MN 55114, United States
Mark Sands, Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH 44195, United States
Raed A Dweik, Adriano R Tonelli, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: Ascha M participated in writing and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted; Abuqayyas S participated in interpretation of the results, writing and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted; Hanouneh I interpretation of the results, writing and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted; Alkukhun L participated in the data collection, interpretation of the results and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted; Sands M participated in the interpretation of the results and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted; Dweik RA participated in the conception of the study, interpretation of the results and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted; Tonelli AR participated in the conception, design of the study, data analysis, interpretation of the results, writing and critical revision of the manuscript for important intellectual content and final approval of the manuscript submitted.
Institutional review board statement: The study was reviewed and approved by the Cleveland Clinic Foundation Institutional Review Board.
Informed consent statement: Written informed consent was waived for study participants.
Conflict-of-interest statement: None of the authors have significant conflicts of interest with any companies or organization whose products or services may be discussed in this article.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at tonella@ccf.org. Participants gave informed consent for data sharing.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Adriano R Tonelli, MD, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195, United States. tonella@ccf.org
Telephone: +1-216-4440812 Fax: +1-216-4456024
Received: December 22, 2015
Peer-review started: December 23, 2015
First decision: January 15, 2016
Revised: January 21, 2016
Accepted: March 14, 2016
Article in press: March 16, 2016
Published online: April 18, 2016
Processing time: 111 Days and 9.1 Hours
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: Transjugular intrahepatic portosystemic shunt; Transjugular portosystemic shunts; Right atrial pressure; Outcomes; Mortality

Core tip: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure accompanied by morbidity and mortality. We hypothesize that echocardiographic and hemodynamic determinations obtained at the time of TIPS can provide prognostic information that will enhance risk stratification of patients. We measured echocardiographic and hemodynamic variables before and immediately after the TIPS procedure in a large cohort of patients at our institution. Our findings corroborate previous literature stating that right atrial pressure increased after TIPS. Our study demonstrates several predictors of long-term mortality after TIPS, such as age, splenectomy, and Model for End-stage Liver Disease score; this data can help assess the risk for patients undergoing TIPS.