Division of Gastroenterology.
Cardiology Unit.
Eur J Gastroenterol Hepatol. 2021 Dec 1;33(1S Suppl 1):e464-e470. doi: 10.1097/MEG.0000000000002151.
Left ventricular diastolic dysfunction (LVDD) in cirrhotics are associated with circulatory dysfunction, hepatorenal syndrome (HRS) and heart failure in stressful conditions. Transjugular intrahepatic portosystemic shunt (TIPS) exacerbates the hyperdynamic circulation and challenges cardiac function. We evaluated the incidence and the impact of LVDD in cirrhotic candidates to TIPS for refractory ascites.
Among 135 patients who underwent TIPS for refractory ascites, 63 cases (child B/C 53/10, Na-model for end-stage liver disease 16.5 ± 0.9) who had 2D-transthoracic-echocardiography with tissue-Doppler-imaging pre-TIPS were retrospectively analysed (group A); in 23 cases cardiac and hormonal assessment before and after TIPS was available. 41 cirrhotics without refractory ascites treated by banding ligation for variceal re-bleeding were used as controls (group B).
The prevalence of LVDD was higher in group A (59%; 22% with grade ≥2) as compared to group B (35%; 7% with grade ≥2) (P < 0.01 and P < 0.03). A lack of clinical response to TIPS occurred in 10 patients, all with LVDD (P < 0.03 vs. no LVDD) and in patients with grade ≥2 LVDD mostly (P < 0.02 vs. grade 1). Central venous pressure >20 mmHg after TIPS and left ventricular end-diastolic volume at basal were predictors of no response to TIPS (P = 0.01 and P = 0.004, respectively), which was an independent predictor of death. Elevated levels of NT-proBNP 3 days after TIPS were associated with advanced cardiac dysfunction (P = 0.005).
NT-proBNP and careful LVDD investigation are useful to better select patients and to predict clinical response and mortality after TIPS.
肝硬化患者的左心室舒张功能障碍（LVDD）与循环功能障碍、肝肾综合征（HRS）和应激条件下的心衰有关。经颈静脉肝内门体分流术（TIPS）加重了高动力循环，并对心脏功能构成挑战。我们评估了 TIPS 治疗难治性腹水的肝硬化患者中 LVDD 的发生率和影响。
在 135 例因难治性腹水而行 TIPS 的患者中，回顾性分析了 63 例（Child-Pugh B/C 53/10，终末期肝病模型 16.5±0.9）在 TIPS 前进行 2D 经胸超声心动图和组织多普勒成像的患者（A 组）；在 23 例患者中，TIPS 前后的心脏和激素评估是可用的。41 例因静脉曲张再出血而行套扎结扎治疗的肝硬化患者作为对照（B 组）。
A 组 LVDD 的患病率高于 B 组（59%；22%为 2 级以上）（P<0.01 和 P<0.03）。10 例患者对 TIPS 无临床反应，均有 LVDD（P<0.03 与无 LVDD），且大多数为 2 级以上 LVDD（P<0.02 与 1 级）。TIPS 后中心静脉压>20mmHg 和基础左心室舒张末期容积是对 TIPS 无反应的预测因素（P=0.01 和 P=0.004），这是死亡的独立预测因素。TIPS 后 3 天 NT-proBNP 水平升高与晚期心脏功能障碍有关（P=0.005）。
NT-proBNP 和仔细的 LVDD 调查有助于更好地选择患者，并预测 TIPS 后的临床反应和死亡率。
