Let atrial dysfunction is an independent predictor of mortality in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt
Authors: Meucci MC , Hoogerduijn Strating M , Butcher SC , Van Rijswijk CSP , Van Hoek B , Delgado V , Bax JJ , Tushuizen ME , Ajmone Marsan N 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Transjugular intrahepatic portosystemic shunt (TIPS) is widely used to treat portal hypertension-related complications in patients with liver cirrhosis. Left ventricular diastolic dysfunction (LVDD) is associated with an increased risk of cardiac decompensation after TIPS, but its predictive value on long-term survival of TIPS candidates is currently unknown. In addition, the assessment of left atrial (LA) reservoir function, which recently emerged as sensitive marker of LVDD, has never been studied in this population.

Purpose
The main objectives were 1) to evaluate the association between LVDD, assessed according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium (revised from the 2016 ASE/EACVI guidelines), and long-term survival in cirrhotic patients undergoing TIPS 2) to investigate the additive prognostic value of LA reservoir strain, measured by speckle-tracking echocardiography.

Methods
Patients with liver cirrhosis treated by TIPS were retrospectively evaluated. All subjects received an echocardiographic examination few weeks before the procedure. Threshold for LA reservoir strain (≤35%) to identify LA dysfunction was chosen based on the median value in the current population and on previously suggested cut-off value from the literature. The primary endpoint of the study was all-cause mortality.

Results
A total of 129 patients (61 ± 12 years; 61 % men) were included. According to the algorithm of the Cirrhotic Cardiomyopathy Consortium, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (LA reservoir strain ≤35%) was found in 67 (52%) patients. After a median follow-up of 36 months (interquartile range: 12-80), 65 (50%) patients died. Kaplan–Meier analysis for all-cause mortality at 4 years demonstrated a significant reduction in survival for more advanced grades of LVDD (log-rank p = 0.007) (Figure 1A). Furthermore, patients with LA dysfunction (LA reservoir strain ≤35%) had a higher cumulative event rate versus patients with preserved LA function (log-rank p = 0.001) (Figure 1B). Multivariable Cox regression analysis identified MELD (model for end-stage liver disease) score (Hazard ratio:1.06; p = 0.003), hemoglobin (Hazard ratio:0.74; p = 0.022) and LA reservoir strain (Hazard ratio:0.96; p = 0.005) as independent predictor of mortality (Figure 2). Excluding LA reservoir strain from the model, more advanced grades of LVDD (grade 2 and indeterminate function) became associated with the outcome. Of note, LA reservoir strain provided incremental prognostic value to the model including MELD score, hemoglobin and grades of LVDD (p = 0.004).

Conclusions
LA dysfunction, assessed by LA reservoir strain with speckle-tracking echocardiography, is an independent predictor of long-term mortality in in cirrhotic patients treated with TIPS. Abstract Figure. Abstract Figure.