Mo1898 Cirrhosis Etiology and Child-Pugh Class Affect the Diagnostic Accuracy of Platelet Count/Spleen Diameter Ratio in Predicting Esophageal Varices. A Meta-Regression Analysis

Abstract

Introduction and Aims: Acute blood volume shift from splanchnic to systemic circulation after TIPS is known to increase right atrial pressure (RAP), pulmonary artery and pulmonary artery wedge pressure, and may cause SHF. Incidence of and factors associated with SHF after TIPS are largely unknown. This study assessed SHF incidence, explored pre-TIPS predictors, and ascertained clinical presentation and outcomes in post-TIPS SHF patients at a large urban tertiary care center.Methods: In this IRB approved retrospective case control study, we identified patients who received new TIPS from 1995 to 2014 from a prospectively maintained TIPS database. PreTIPS evaluation includes determination of portal vein patency and cardiac function. Typically, those with significant pre-existing pulmonary hypertension are not offered TIPS. SHF was defined as otherwise unexplained new-onset dyspnea, hypoxemia, radiologic pulmonary edema, increased need for diuretics, or need for intubation within seven days. Deaths occurring within 7 days due to septic shock/continuing gastrointestinal bleed/ multi-organ failure were excluded. A control group consisted of a random sample of 40 from the same TIPS data base. Univariable analysis was performed to assess differences between subjects with and without post-TIPS heart failure. Results: Of 934 new TIPS performed during the study period, 883 met inclusion criteria. Eight (0.9%) developed SHF, usually manifested by hypoxemia (57%) or dyspnea (28%) within 48 hours. One (12.5%) died on day 12 (due to persistent hypoxia, renal failure and worsening encephalopathy). SHF patients and controls were similar with respect to pre-TIPS diastolic dysfunction, alcohol use, duration of cirrhosis, MELD score, pulmonary hypertension and diuretic use. SHF patients had higher pre-TIPS RAP (10.5±7.3 vs 6.7±4.0) (p=0.04) and portal vein pressure (30.6±6.0 vs 24.7±5.5) (p=0.009), higher albumin level (p=0.02), higher prothrombin time (p=0.04) and were of older age (p=0.04). Intubation was more frequent in SHF (p=0.02). Interestingly, one patient in the control groupwith severe pulmonary hypertension underwent TIPS with an uneventful outcome. Conclusion: Post-TIPS SHF is rare but potentially fatal. Higher pre-TIPS RAP and portal vein pressures, older age and higher prothrombin time are likely to predispose. Formulation of a risk prediction model and subsequent external validation will help identify patients with these risk factors for whom added surveillance may be warranted.