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The Toulouse algorithm identifies patients with increased risk of cardiac decompensation only in patients with TIPS
Emma Vanderschueren1, Youri Bekhuis2, Jan Clerick3
1Department of Gastroenterology and Hepatology, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Herestraat 49, 3000 Leuven, Belgium.
Insights
Cardiac decompensation (CD) affects about 1 in 10 patients after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement. The Toulouse algorithm can predict CD risk, particularly in patients with refractory ascites (RA).
Area of Science:
- Hepatology
- Cardiology
- Interventional Radiology
Background:
- Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement is a critical intervention for managing complications of portal hypertension.
- A significant concern post-TIPS is the potential for cardiac decompensation (CD) due to altered hemodynamics.
- Predicting CD risk is crucial for patient management and optimizing outcomes after TIPS.
Purpose of the Study:
- To determine the incidence of cardiac decompensation (CD) following TIPS placement.
- To identify baseline variables associated with the development of CD post-TIPS.
- To evaluate the predictive accuracy of the Toulouse algorithm for CD risk in patients undergoing TIPS.
Main Methods:
- Retrospective review of 106 patients who underwent TIPS for variceal bleeding or refractory ascites.
- Analysis included echocardiography and NT-proBNP levels at baseline.
- Competing risk regression was used to identify predictors of CD, and the Toulouse algorithm's validity was assessed.
Main Results:
- Cardiac decompensation (CD) occurred in 11.3% of patients post-TIPS.
- In patients with refractory ascites (RA), baseline age, albumin, and NT-proBNP predicted CD.
- The Toulouse algorithm accurately predicted CD risk in the RA group, with risk increasing across low and high-risk categories.
Conclusions:
- Cardiac decompensation is a notable complication after TIPS, affecting approximately 1 in 10 patients.
- The Toulouse algorithm demonstrates utility in identifying patients at risk for CD, specifically within the refractory ascites (RA) population.
- High-risk stratification warrants close patient monitoring but should not contraindicate necessary TIPS procedures.
Introduction And Objectives:
TIPS placement is an effective, possibly life-saving, treatment for complications of portal hypertension. The pressure shift induced by the stent can lead to cardiac decompensation (CD). We investigated the incidence of CD, possible variables associated with CD and the validity of the Toulouse algorithm for risk prediction of CD post-TIPS.
Patients And Methods:
A total of 106 patients receiving TIPS for variceal bleeding (VB, 41.5%) or refractory ascites (RA, 58.5%) with available echocardiography and NT-proBNP results were included and retrospectively reviewed. Development of CD between time of TIPS placement and occurrence of liver transplantation, death or loss-to-follow-up was recorded. Competing risk regression analysis was performed to assess which baseline variables predicted occurrence of CD post-TIPS.
Results:
A total of 12 patients (11.3%) developed CD after a median of 11.5 days (IQR 4 to 56.5) post-TIPS. Multivariate regression showed age (HR 1.06, p = 0.019), albumin (HR 1.10, p = 0.009) and NT-proBNP (HR 1.00, p = 0.023) at baseline predicted CD in the RA group. No clear predictors were found in those receiving TIPS for VB. Correspondingly, the Toulouse algorithm successfully identified patients at risk for CD, however only in the RA population (zero risk 0% vs. low risk 12.5% vs. high risk 35.3% with CD; p = 0.003).
Conclusions:
CD is not an infrequent complication post-TIPS occurring in 1/10 patients. The Toulouse algorithm can identify patients at risk of CD, though only in patients receiving TIPS for RA. Allocation to the high-risk category warrants close monitoring but should not preclude TIPS placement.
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