Abstract
In Europe, liver cirrhosis represents the fourth-most common cause of death, being responsible for 170,000 deaths and 5500 liver transplantations per year. The main driver of its decompensation is portal hypertension, whose progression radically changes the prognosis of affected patients. Transjugular intrahepatic portosystemic shunt (TIPS) is one of the main therapeutic strategies for these patients as it reverts portal hypertension, thus improving survival. However, the coexistence of portal hypertension and pulmonary hypertension or heart failure is considered a contraindication to TIPS. Nevertheless, in the latest guidelines, the definition of heart failure has not been specified. It is unclear whether the contraindication concerns the presence of clinical signs and symptoms of heart failure or hemodynamic changes in the right heart-pulmonary circulation. Moreover, data about induced right heart volume overload after TIPS and the potential development of heart failure and pulmonary hypertension is currently scanty and controversial. In this article we revise this issue in finding predictors of cardiac performance after TIPS procedure. Performing a fluid challenge during right heart catheterization might be a promising expedient to test the adaptation of the right ventricle to a sudden increase in preload in the first few months after TIPS. This test may unmask a potential cardiac inability to sustain the hemodynamic load after TIPS, allowing for a clearer definition of heart failure and, consequently, a more robust indication to TIPS.
Highlights
Portal Hypertension: Epidemiology and Clinic Impact In Europe, liver cirrhosis is the cause of 5500 liver transplantations per year and it constitutes the fourth most-common cause of death, resulting in 170,000 deaths per year [1]
The leading cause of morbidity and mortality in patients affected by liver cirrhosis is portal hypertension [2], which ensues/occurs progressively during the course of the disease [3]
The pressure increase beyond this threshold is defined as clinically significant portal hypertension (CSPH)
Summary
In Europe, liver cirrhosis is the cause of 5500 liver transplantations per year and it constitutes the fourth most-common cause of death, resulting in 170,000 deaths per year [1]. The pressure increase beyond this threshold is defined as clinically significant portal hypertension (CSPH). At this stage, patients usually have gastroesophageal varices and/or ascites. The introduction of transjugular intrahepatic portosystemic shunt (TIPS) in clinical practice represented, in the last 20 years, a step forward for treatment improvement for patients with untreatable complications of portal hypertension. Clinical indications for TIPS include acute variceal bleeding refractory to treatment, recurrent or refractory ascites, refractory hepatic hydrothorax, hepatorenal syndrome, non-cirrhotic portal hypertension (Budd-Chiari syndrome, portosinusoidal vascular disease). Blood shunting results in an increase in cardiac output (CO) and pulmonary artery pressure and a decrease in systemic vascular resistances [16]. It was shown that volume overload induced by TIPS placement may be associated with increased PAWP and, postcapillary pulmonary hypertension (group II WHO classification) [17,19,20,21,22,23,24] (Table 1)
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