Letter: cardiovascular complications in patients with transjugular intrahepatic portosystemic shunt - the necessity for regular cardiac surveillance. Authors' reply.

Abstract

With great interest we read the letter by Dr Lu,1 who commented on our findings of long-term cardiac follow-up in patients with a transjugular intrahepatic portosystemic shunt (TIPSS).2, 3 We do agree with the author that data on cardiac long-term follow-up after TIPSS are rare. In fact, our study was the first to assess cardiac function at greater 1-year post TIPSS and we were showed that left atrial diameter, left ventricular end-diastolic diameter and pulmonary artery systolic pressure (PASP) increased during long-term follow-up. However, we were not able to assess to which extent this correlated with clinical symptoms of cardiac disease, which had not been recorded for our study. Despite this, we decided to nevertheless start performing yearly echocardiographic follow-up in our TIPSS patients in order to detect early the worsening of cardiac function, especially since a high number of our TIPSS patients are on the waiting list for liver transplantation as well. Cardiopulmonary assessment is mandatory during the evaluation process of potential liver transplant candidates and should include an echocardiography examination and screening for pulmonary hypertension.4 Increased pulmonary artery pressure (PAP) is a known risk factor for peri-transplant cardiopulmonary mortality: mean pulmonary artery pressure (MPAP) ≥35 mmHg resulted in a mortality rate of 52% and a rate of cardiopulmonary mortality of 48%. In contrast, no death for cardiopulmonary reason was seen in patients with a MPAP <35 mmHg.5 PASP measured during echocardiography allows a first assessment of pulmonary hypertension and showed a weak correlation with pulmonary artery pressure measured on right heart catheterization in liver transplant candidates.6 Sensitivity for detection of portopulmonary hypertension, in a further study, was 80% and specificity was 91% at a cut-off ≥40 mmHg.7 It was also found to independently correlate with length of intensive care unit and hospital stay as well as with time on ventilator after liver transplantation.8 Overall, we agree with Dr. Lu that more studies are needed to further elucidate the long-term influence of TIPSS on cardiopulmonary function. Nevertheless, considering the findings of PASP increase after TIPSS, the high rate of mortality in patients with portopulmonary hypertension and the association of increased pulmonary artery pressure and mortality after liver transplantation, we advocate to perform regular cardiac surveillance post TIPSS. The authors' declarations of personal and financial interests are unchanged from those in the original article.2