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Scientific letter
DOI: 10.1016/j.rgmxen.2021.03.001
Open Access
Available online 7 April 2021
Acute heart failure following transjugular intrahepatic portal-systemic shunting corrected through transient balloon occlusion
Insuficiencia cardiaca aguda posterior a derivación portosistémica transyugular intrahepática corregida por medio de oclusión transitoria con globo
B. Valdivia-Correaa, V. Reynier-Garzab, N. Chávez-Tapiaa, G. Alanis-Estradab, D. Araiza-Garaygordobilb,
Corresponding author

Corresponding author at: Juan Badiano 1, Sección XVI Tlalpan, Mexico City, Mexico. Tel.: 55 2895 6977.
a Departamento de Gastroenterología, Clínica y Fundación Médica Sur, Mexico City, Mexico
b Unidad Coronaria, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Table 1. Pre-TIPS and post-TIPS hemodynamic measurements.
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A transjugular intrahepatic portosystemic shunt (TIPS) relieves the portal hypertension (PHT) that can lead to the formation of ascites. Therefore, it should be able to reduce PHT recurrence and the incidence of complications, as well as improve survival in those patients.1,2 However, data on extrahepatic factors that could specifically predict cardiovascular complications after TIPS placement are scarce.

A 59-year-old woman with cryptogenic cirrhosis (Child-Pugh B: 7 points, slightly modified Child-Pugh B: 7 points+MELD 15 points+MELD-Na: 16 points) was admitted to a tertiary care hospital for TIPS assessment due to refractory and recurrent ascites. Besides a history of active smoking, she had no functional limitations and no cardiac history. The patient stated that she did not drink alcohol. Before hospital admission, she had been prescribed a low-sodium diet and adequate diuretic doses, but she presented with clinically significant complications (creatinine >2.0mg/dl) that were managed conservatively. The patient then manifested tense ascites and was treated with serial large-volume paracentesis and albumin administration (8g/l of fluid removed) on more than 3 occasions within 12 months, with rapid recurrence. Spontaneous bacterial peritonitis was ruled out each time. The hepatologist and interventional radiologist began a pre-procedural evaluation. Upon admission, the laboratory work-up showed volume-responsive acute kidney injury (RIFLE 1, AKIN II) with a basal creatinine level of 1.85mg/dl and a control of 1.2mg/dl. The rest of the laboratory test results were hemoglobin 11.4g/dl, hematocrit 34.3%, platelet count 137,000/mm3, prothrombin time 11.5s, INR 1.04, total bilirubin 1.64mg/dl, and albumin 3.9g/dl. A chest x-ray revealed no alterations. A transthoracic echocardiogram showed normal ventricular function, a left ventricular ejection fraction of 70%, an E/A wave ratio of 1.2, minimal tricuspid regurgitation, and a pulmonary arterial systolic pressure of 28mmHg (Fig. 1A). A duplex ultrasound showed normal portal vein patency and no liver masses. Twenty-four hours later, with the patient under general anesthesia, the interventional radiologist inserted a TIPS, using an 8mm internal diameter ×10cm long Gore® Viatorr® stent-graft (W.L. Gore, Flagstaff, AZ, USA), per standard protocol, between the right portal vein and the right hepatic vein. After the procedure, there was a decrease to –4mmHg in the portoatrial gradient (portal vein pressure 16mmHg – right atrial pressure 20mmHg). Table 1 shows the hemodynamic parameters.

Figure 1.

Pre-transjugular intrahepatic portosystemic shunt (TIPS) (A, C) and post-TIPS (B, D) echocardiogram measurements. A) Pre-TIPS TAPSE of 18.8mm. B) Post-TIPS TAPSE of 14.4mm. C) Pre-TIPS E/A wave ratio of 1.2. D) Post-TIPS E/A wave ratio of 1.54.

TAPSE: tricuspid annular plane systolic excursion.

Table 1.

Pre-TIPS and post-TIPS hemodynamic measurements.

  Pre-TIPS  Post-TIPS 
Right atrial pressure (mmHg)  12  20 
Portal vein pressure (mmHg)  22  16 
Portoatrial gradient (mmHg)  10  –4 

Twenty-four hours after TIPS placement, the patient presented with dyspnea at rest and the jugular venous pressure was markedly elevated. The abdomen was distended, with tense ascites, and no peripheral edema was present. A chest x-ray identified pleural effusion. A follow-up echocardiogram revealed a left ventricular ejection fraction of 75%, right cavity dilatation, paradoxical septal movement, severe tricuspid regurgitation, reduced tricuspid annular plane systolic excursion (TAPSE), increased filling pressures, and a pulmonary arterial systolic pressure of 40mmHg (Fig. 1B). No response to diuretic and vasopressor treatment was observed. Due to clinical deterioration 72h after the original TIPS placement, a balloon occlusion was performed. The patient’s condition gradually improved, and she was discharged from the hospital. She was also considered a candidate for liver transplantation. During follow-up, there were no signs or symptoms of heart failure and a normal echocardiogram was documented.

After the re-direction of the mesenteric flow into the systemic circulation resulting from TIPS placement, an increase in central venous pressure, right atrial pressure, mean pulmonary pressure, pulmonary artery wedge pressure, cardiac index, and stroke volume3,4 have been observed. A study of 158 patients undergoing TIPS insertion showed an increased left atrial diameter and left ventricular end-diastolic diameter, after 1 to 5 years of follow-up.5 Diastolic dysfunction is often found in cirrhotic cardiomyopathy6 and significant change in pulmonary artery systolic pressure has also been noted at short-term and long-term follow-up.7 Even when hemodynamic changes after TIPS placement have been properly described, there are few studies that identify potential predictors of cardiovascular disfunction.

A prospective study of 934 TIPS procedures recently identified factors that may predispose patients to the development of symptomatic heart failure (SHF) after TIPS placement. Patients with SHF had higher pre-TIPS right atrial (RA) pressure (p=0.03) and portal vein pressure (p=0.01), higher albumin (p=0.02), and higher prothrombin time (p=0.02). In the case of our patient, pre-TIPS RA pressure was also elevated. RA pressure is used as the reference after shunt creation, because the diverted portal flow artifactually raises the pressure within the outflow hepatic vein that drains the TIPS.8

In the case presented herein, acute heart failure, with impaired diastolic function and tricuspid valve regurgitation,9 was sufficiently severe to preclude the benefits of portal systemic shunting. Despite inotropic and diuretic therapy, the patient persisted with systemic congestion and acute kidney injury. Much remains to be clarified regarding cardiac evaluation before placing a TIPS, including which patients will tolerate hemodynamic changes after said placement.

In conclusion, cardiac complications after TIPS insertion may preclude the positive effects of that therapy in patients with complications of portal hypertension. Pre-procedure evaluation that includes a cardiology consultation and routine transthoracic echocardiography is recommended in all cases. Extending the assessment to include advanced echocardiographic techniques, the dynamic evaluation of ventricular diastolic and systolic function, and the degree of tricuspid insufficiency may be appropriate in particular cases. Further studies on clinical factors, biomarkers, and cardiovascular imaging findings that may predict cardiac complications after TIPS placement are needed.

Ethical considerations

Informed consent was not requested for the publication of the present case because no personal data that could identify the patient was published. The present case report was not submitted to an ethics committee.

Financial disclosure

No specific grants were received from public sector agencies, the business sector, or non-profit organizations in relation to this article.

Conflict of interest

The authors declare that there is no conflict of interest.

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Please cite this article as: Valdivia-Correa B, Reynier-Garza V, Chávez-Tapia N, Alanis-Estrada G, Araiza-Garaygordobil D. Insuficiencia cardiaca aguda posterior a derivación portosistémica transyugular intrahepática corregida por medio de oclusión transitoria con globo. Revista de Gastroenterología de México. 2021.

Copyright © 2020. Asociación Mexicana de Gastroenterología
Revista de Gastroenterología de México

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