Ascha Mona, Abuqayyas Sami, Hanouneh Ibrahim, Alkukhun Laith, Sands Mark, Dweik Raed A, Tonelli Adriano R
Mona Ascha, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States.
World J Hepatol. 2016 Apr 18;8(11):520-9. doi: 10.4254/wjh.v8.i11.520.
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.
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).
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).
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.
探讨经颈静脉肝内门体分流术（TIPS）时获得的超声心动图和血流动力学测定结果能否提供预后信息，以加强对患者的风险分层。
我们回顾了2003年7月至2011年12月在我院接受TIPS的467例患者的病历。我们记录了患者的人口统计学信息、潜在肝病、TIPS的适应证、基线实验室值、TIPS时的血流动力学测定结果以及TIPS前后的超声心动图测量值。我们记录了可能影响血流动力学和超声心动图测定结果的患者合并症。我们还计算了终末期肝病模型（MELD）评分和Child-Turcotte-Pugh（CTP）分级。记录了以下TIPS前后的超声心动图测定结果：左心室射血分数、右心室（RV）收缩压、主观RV扩张和主观RV功能。我们记录了以下血流动力学测量值：TIPS前后的右心房（RA）压力、TIPS前后的下腔静脉压力、游离肝静脉压力、TIPS前后的门静脉压力以及肝静脉压力梯度（HVPG）。
我们回顾了418例接受TIPS的门静脉高压患者。RA压力平均升高±标准差为4.8±3.9 mmHg（P<0.001），HVPG降低6.8±3.5 mmHg（P<0.001）。在多变量线性回归分析中，较高的MELD评分、较低的血小板计数、脾切除术和较高的门静脉压力是RA压力升高的独立预测因素（R=0.55）。多变量分析中三个变量预测了TIPS后3个月的死亡率：年龄、MELD评分和CTP分级C。TIPS后RA压力的变化预测长期死亡率（每变化1 mmHg，HR=1.03，95%CI：1.01-1.06，P<0.012）。
TIPS后RA压力立即升高，尤其是在肝功能较差、门静脉高压、急诊TIPS置入和有脾切除术史的患者中。TIPS后RA压力升高与死亡率增加相关。年龄、脾切除术、MELD评分和CTP分级是TIPS后长期死亡率的独立预测因素。
