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Current Hepatology Reports
Published in: Current Hepatology Reports 3/2017

01-09-2017 | Portal Hypertension (J Abraldes and E Tsochatzis, Section Editors)

Cardiovascular Effects of a Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis

Authors: Troels M. Busk, Søren Møller, Flemming Bendtsen

Published in: Current Hepatology Reports | Issue 3/2017

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Abstract

Purpose of Review

Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) has proven effective in alleviating complications to portal hypertension such as refractory ascites and variceal bleeding in patients with cirrhosis. Moreover, it increases survival in selected patient groups. However, TIPS also causes marked circulatory changes and a central concern has been whether this could negatively affect cardiac function. Therefore, this review aims to critically discuss our knowledge on cardiovascular effects of a TIPS in cirrhosis.

Recent Findings

These suggest that TIPS does not worsen cardiac function. Careful cardiac evaluation prior to TIPS is, however, a prerequisite in order to prevent cardiac complications after TIPS insertion.

Summary

The focus on cirrhotic cardiomyopathy has raised the awareness on specific procedures such as TIPS. Thus, previous studies have demonstrated that TIPS seemingly worsens cardiac function with a negative effect on ascites clearance and survival. However, recent studies have not been able to establish this deleterious interplay and the overall frequency of cardiac failure after TIPS still remains low. Hence, TIPS seems to be safe with regard to cardiac function in patients with cirrhosis.
Literature
1.
Rossle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut. 2010;59(7):988–1000.PubMedCrossRef
2.
•• Sauerbruch T, Mengel M, Dollinger M, Zipprich A, Rossle M, Panther E, et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology. 2015;149(3):660–8. An important study demonstrating the efficacy of TIPS on variceal bleeding. PubMedCrossRef
3.
Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010 Jun 24;362(25):2370–9.PubMedCrossRef
4.
•• Bureau C, Thabut D, Oberti F, Dharancy S, Carbonell N, Bouvier A, et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology. 2017;152(1):157–63. An important study showing that TIPS increases survival in patients with recurrent ascites. PubMedCrossRef
5.
Salerno F, Camma C, Enea M, Rossle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology. 2007;133(3):825–34.PubMedCrossRef
6.
Wong W, Liu P, Blendis L, Wong F. Long-term renal sodium handling in patients with cirrhosis treated with transjugular intrahepatic portosystemic shunts for refractory ascites. Am J Med. 1999;106(3):315–22.PubMedCrossRef
7.
Wong F, Sniderman K, Liu P, Blendis L. The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt. Gastroenterology. 1997;112(3):899–907.PubMedCrossRef
8.
Gerbes AL, Gulberg V, Waggershauser T, Holl J, Reiser M. Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: comparison of patients with ascites, with refractory ascites, or without ascites. Hepatology. 1998;28(3):683–8.PubMedCrossRef
9.
Salerno F, Cazzaniga M, Pagnozzi G, Cirello I, Nicolini A, Meregaglia D, et al. Humoral and cardiac effects of TIPS in cirrhotic patients with different “effective” blood volume. Hepatology. 2003;38(6):1370–7.PubMed
10.
11.
Ruiz-del-Arbol L, Monescillo A, Arocena C, Valer P, Gines P, Moreira V, et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology. 2005;42(2):439–47.PubMedCrossRef
12.
Ruiz-del-Arbol L, Urman J, Fernandez J, Gonzalez M, Navasa M, Monescillo A, et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology. 2003;38(5):1210–8.PubMedCrossRef
13.
Krag A, Bendtsen F, Henriksen JH, Moller S. Low cardiac output predicts development of hepatorenal syndrome and survival in patients with cirrhosis and ascites. Gut. 2010 Jan;59(1):105–10.PubMedCrossRef
14.
Colombato LA, Spahr L, Martinet JP, Dufresne MP, Lafortune M, Fenyves D, et al. Haemodynamic adaptation two months after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients. Gut. 1996;39(4):600–4.PubMedPubMedCentralCrossRef
15.
Huonker M, Schumacher YO, Ochs A, Sorichter S, Keul J, Rossle M. Cardiac function and haemodynamics in alcoholic cirrhosis and effects of the transjugular intrahepatic portosystemic stent shunt. Gut. 1999;44(5):743–8.PubMedPubMedCentralCrossRef
16.
Lotterer E, Wengert A, Fleig WE. Transjugular intrahepatic portosystemic shunt: short-term and long-term effects on hepatic and systemic hemodynamics in patients with cirrhosis. Hepatology. 1999;29(3):632–9.PubMedCrossRef
17.
•• Saugel B, Mair S, Meidert AS, Phillip V, Messer M, Nennstiel S, et al. The effects of transjugular intrahepatic portosystemic stent shunt on systemic cardiocirculatory parameters. J Crit Care. 2014;29(6):1001–5. Recent study demonstrating the beneficial effects of TIPS on cardiac and renal function. PubMedCrossRef
18.
Busk TM, Bendtsen F, Moller S. Cardiac and renal effects of a transjugular intrahepatic portosystemic shunt in cirrhosis. Eur J Gastroenterol Hepatol. 2013;25(5):523–30.PubMedCrossRef
19.
Rabie RN, Cazzaniga M, Salerno F, Wong F. The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt. Am J Gastroenterol. 2009;104(10):2458–66.PubMedCrossRef
20.
Cazzaniga M, Salerno F, Pagnozzi G, Dionigi E, Visentin S, Cirello I, et al. Diastolic dysfunction is associated with poor survival in patients with cirrhosis with transjugular intrahepatic portosystemic shunt. Gut. 2007;56(6):869–75.PubMedPubMedCentralCrossRef
21.
Trevisani F, Merli M, Savelli F, Valeriano V, Zambruni A, Riggio O, et al. QT interval in patients with non-cirrhotic portal hypertension and in cirrhotic patients treated with transjugular intrahepatic porto-systemic shunt. J Hepatol. 2003;38(4):461–7.PubMedCrossRef
22.
Wannhoff A, Hippchen T, Weiss CS, Friedrich K, Rupp C, Neumann-Haefelin C, et al. Cardiac volume overload and pulmonary hypertension in long-term follow-up of patients with a transjugular intrahepatic portosystemic shunt. Aliment Pharmacol Ther. 2016;43(9):955–65.PubMedCrossRef
23.
24.
Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodes J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988;8(5):1151–7.PubMedCrossRef
25.
26.
Kiszka-Kanowitz M, Henriksen JH, Moller S, Bendtsen F. Blood volume distribution in patients with cirrhosis: aspects of the dual-head gamma-camera technique. J Hepatol. 2001;35(5):605–12.PubMedCrossRef
27.
Henriksen JH, Bendtsen F, Sorensen TI, Stadeager C, Ring-Larsen H. Reduced central blood volume in cirrhosis. Gastroenterology. 1989;97(6):1506–13.PubMedCrossRef
28.
Moller S, Henriksen JH, Bendtsen F. Central and noncentral blood volumes in cirrhosis: relationship to anthropometrics and gender. Am J Physiol Gastrointest Liver Physiol. 2003;284(6):G970–9.PubMedCrossRef
29.
Krag A, Moller S, Pedersen EB, Henriksen JH, Holstein-Rathlou NH, Bendtsen F. Impaired free water excretion in child C cirrhosis and ascites: relations to distal tubular function and the vasopressin system. Liver Int. 2010;30(9):1364–70.PubMedCrossRef
30.
Moller S, Bendtsen F, Henriksen JH. Determinants of the renin-angiotensin-aldosterone system in cirrhosis with special emphasis on the central blood volume. Scand J Gastroenterol. 2006;41(4):451–8.PubMedCrossRef
31.
Moller S, Iversen JS, Henriksen JH, Bendtsen F. Reduced baroreflex sensitivity in alcoholic cirrhosis: relations to hemodynamics and humoral systems. Am J Physiol Heart Circ Physiol. 2007;292(6):H2966–72.PubMedCrossRef
32.
Moller S, Iversen JS, Krag A, Bie P, Kjaer A, Bendtsen F. Reduced baroreflex sensitivity and pulmonary dysfunction in alcoholic cirrhosis: effect of hyperoxia. Am J Physiol Gastrointest Liver Physiol. 2010;299(3):G784–90.PubMedCrossRef
33.
34.
• Wiese S, Hove JD, Bendtsen F. Moller S. Cirrhotic cardiomyopathy: pathogenesis and clinical relevance. Nat Rev Gastroenterol Hepatol. 2014;11(3):177–86. Recent review on cirrhotic cardiomyopathy. PubMedCrossRef
35.
36.
Gines P, Uriz J, Calahorra B, Garcia-Tsao G, Kamath PS, Del Arbol LR, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology. 2002;123(6):1839–47.PubMedCrossRef
37.
Braverman AC, Steiner MA, Picus D, White H. High-output congestive heart failure following transjugular intrahepatic portal-systemic shunting. Chest. 1995;107(5):1467–9.PubMedCrossRef
38.
Krag A, Bendtsen F, Burroughs AK, Moller S. The cardiorenal link in advanced cirrhosis. Med Hypotheses. 2012;79(1):53–5.PubMedCrossRef
39.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233–70.PubMedCrossRef
40.
Jensen MT, Sogaard P, Andersen HU, Bech J, Fritz HT, Biering-Sorensen T, et al. Global longitudinal strain is not impaired in type 1 diabetes patients without albuminuria: the Thousand & 1 study. JACC Cardiovasc Imaging. 2015;8(4):400–10.PubMedCrossRef
41.
Nagueh SF, Smiseth OA, Appleton CP, Byrd BF III, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29(4):277–314.PubMedCrossRef
42.
Zambruni A, Trevisani F, Caraceni P, Bernardi M. Cardiac electrophysiological abnormalities in patients with cirrhosis. J Hepatol. 2006;44(5):994–1002.PubMedCrossRef
43.
Henriksen JH, Gulberg V, Fuglsang S, Schifter S, Bendtsen F, Gerbes AL, et al. Q-T interval (QT (C)) in patients with cirrhosis: relation to vasoactive peptides and heart rate. Scand J Clin Lab Invest. 2007;67(6):643–53.PubMedCrossRef
44.
Ytting H, Henriksen JH, Fuglsang S, Bendtsen F, Moller S. Prolonged Q-T (c) interval in mild portal hypertensive cirrhosis. J Hepatol. 2005;43(4):637–44.PubMedCrossRef
45.
Henriksen JH, Fuglsang S, Bendtsen F, Christensen E, Moller S. Dyssynchronous electrical and mechanical systole in patients with cirrhosis. J Hepatol. 2002 Apr;36(4):513–20.PubMedCrossRef
46.
Voiosu A, Wiese S, Voiosu T, Bendtsen F, Moller S. Bile acids and cardiovascular function in cirrhosis. Liver Int. 2017.
47.
Fede G, D’Amico G, Arvaniti V, Tsochatzis E, Germani G, Georgiadis D, et al. Renal failure and cirrhosis: a systematic review of mortality and prognosis. J Hepatol. 2012;56(4):810–8.PubMedCrossRef
48.
49.
Cavallin M, Fasolato S, Marenco S, Piano S, Tonon M, Angeli P. The treatment of hepatorenal syndrome. Dig Dis. 2015;33(4):548–54.PubMedCrossRef
50.
Angeli P, Gines P, Wong F, Bernardi M, Boyer TD, Gerbes A, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015;64(4):531–7.PubMedCrossRef
51.
Wong F, Nadim MK, Kellum JA, Salerno F, Bellomo R, Gerbes A, et al. Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis. Gut. 2011;60(5):702–9.PubMedCrossRef
52.
Moller S, Bendtsen F, Henriksen JH. Effect of volume expansion on systemic hemodynamics and central and arterial blood volume in cirrhosis. Gastroenterology. 1995;109(6):1917–25.PubMedCrossRef
53.
Adebayo D, Morabito V, Davenport A, Jalan R. Renal dysfunction in cirrhosis is not just a vasomotor nephropathy. Kidney Int. 2015;87(3):509–15.PubMedCrossRef
54.
Gungor G, Ataseven H, Demir A, Solak Y, Gaipov A, Biyik M, et al. Neutrophil gelatinase-associated lipocalin in prediction of mortality in patients with hepatorenal syndrome: a prospective observational study. Liver Int. 2014;34(1):49–57.PubMedCrossRef
55.
• Busk TM, Bendtsen F, Moller S. Hepatorenal syndrome in cirrhosis: diagnostic, pathophysiological, and therapeutic aspects. Expert Rev Gastroenterol Hepatol. 2016; 1–9. Recent review on renal dysfunction in cirrhosis.
56.
Stadlbauer V, Wright GA, Banaji M, Mukhopadhya A, Mookerjee RP, Moore K, et al. Relationship between activation of the sympathetic nervous system and renal blood flow autoregulation in cirrhosis. Gastroenterology. 2008;134(1):111–9.PubMedCrossRef
57.
Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010;51(1):306.PubMedCrossRef
58.
•• Fili D, Falletta C, Luca A, Hernandez BC, Clemenza F, Miraglia R, et al. Circulatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: relationship with diastolic dysfunction. Dig Liver Dis. 2015;47(12):1052–8. Recent study demonstrating that TIPS insertion is safe in cirrhosis with regards to cardiac function. PubMedCrossRef
59.
Schwartz JM, Beymer C, Althaus SJ, Larson AM, Zaman A, Glickerman DJ, et al. Cardiopulmonary consequences of transjugular intrahepatic portosystemic shunts: role of increased pulmonary artery pressure. J Clin Gastroenterol. 2004;38(7):590–4.PubMedCrossRef
60.
Stanley AJ, Redhead DN, Bouchier IA, Hayes PC. Acute effects of transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure on renal blood flow and cardiopulmonary hemodynamics in cirrhosis. Am J Gastroenterol. 1998;93(12):2463–8.PubMedCrossRef
61.
Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol. 2007;41(Suppl 3):S344–51.PubMedCrossRef
62.
Brensing KA, Textor J, Perz J, Schiedermaier P, Raab P, Strunk H, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut. 2000;47(2):288–95.PubMedPubMedCentralCrossRef
63.
Guevara M, Gines P, Bandi JC, Gilabert R, Sort P, Jimenez W, et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998;28(2):416–22.PubMedCrossRef
64.
Sanyal AJ, Genning C, Reddy KR, Wong F, Kowdley KV, Benner K, et al. The North American study for the treatment of refractory ascites. Gastroenterology. 2003;124(3):634–41.PubMedCrossRef
65.
Merli M, Valeriano V, Funaro S, Attili AF, Masini A, Efrati C, et al. Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS). Am J Gastroenterol. 2002;97(1):142–8.PubMedCrossRef
66.
Fagiuoli S, Bruno R, Debernardi VW, Schepis F, Vizzutti F, Toniutto P, et al. Consensus conference on TIPS management: techniques, indications, contraindications. Dig Liver Dis. 2017;49(2):121–37.PubMedCrossRef
67.
Rudler M, Cluzel P, Corvec TL, Benosman H, Rousseau G, Poynard T, et al. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther. 2014;40(9):1074–80.PubMedCrossRef
68.
Pieper CC, Sprinkart AM, Nadal J, Hippe V, Meyer C, Schild HH, et al. Postinterventional passive expansion of partially dilated transjugular intrahepatic portosystemic shunt stents. J Vasc Interv Radiol. 2015;26(3):388–94.PubMedCrossRef
69.
•• Allegretti AS, Ortiz G, Cui J, Wenger J, Bhan I, Chung RT, et al. Changes in kidney function after transjugular intrahepatic portosystemic shunts versus large-volume paracentesis in cirrhosis: a matched cohort analysis. Am J Kidney Dis. 2016;68(3):381–91. Recent paper showing the beneficial effect of TIPS on renal function in cirrhosis. PubMedCrossRef
Metadata
Title
Cardiovascular Effects of a Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis
Authors
Troels M. Busk
Søren Møller
Flemming Bendtsen
Publication date
01-09-2017
Publisher
Springer US
Published in
Current Hepatology Reports / Issue 3/2017
Electronic ISSN: 2195-9595
DOI
https://doi.org/10.1007/s11901-017-0362-x

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