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Cardiac Function and Haemodynamics in Alcoholic Cirrhosis and Evects of the Transjugular Intrahepatic Portosystemic Stent Shunt

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Cardiac Function and Haemodynamics in Alcoholic Cirrhosis and Evects of the Transjugular Intrahepatic Portosystemic Stent Shunt Gut 1999;44:743–748 743 Cardiac function and haemodynamics in alcoholic cirrhosis and eVects of the transjugular Gut: first published as 10.1136/gut.44.5.743 on 1 May 1999. Downloaded from intrahepatic portosystemic stent shunt M Huonker, Y O Schumacher, A Ochs, S Sorichter, J Keul, M Rössle Abstract seem to be mainly responsible for the fur- Background—A portosystemic stent ther decrease in systemic vascular resist- shunt may impair cardiac function and ance. TIPS may unmask a coexisting haemodynamics. preclinical cardiomyopathy in patients Aims—To investigate the eVects of a tran- with alcoholic cirrhosis and portal hyper- sjugular intrahepatic portosystemic shunt tension. (TIPS) on cardiac function and pulmo- (Gut 1999;44:743–748) nary and systemic circulation in patients Keywords: alcoholic cirrhosis; portosystemic stent with alcoholic cirrhosis. shunt; cirrhotic cardiomyopathy; ventricular function; Patients/Methods—17 patients with alco- pulmonary circulation; systemic circulation holic cirrhosis and recent variceal bleed- ing were evaluated by echocardiography and catheterisation of the splanchnic and It has been known for more than four decades pulmonary circulation before and after that hepatic cirrhosis is associated with cardio- TIPS. The period of catheter measure- vascular abnormalities. The initial studies per- ment was extended to nine hours in nine of formed in the early 1950s documented the the patients. The portal vein was investi- existence of a hyperdynamic circulation in cir- gated by Doppler ultrasound before and rhosis, manifested by increased cardiac output nine hours after TIPS. and reduced systemic vascular resistance.1 Results—Baseline echocardiography Overt heart failure is generally not a prominent showed the left atrial diameter to be feature of hepatic cirrhosis, because the marked slightly increased and the left ventricular peripheral vasodilation reduces the afterload of volume to be in the upper normal range. the left ventricle, thus unloading the heart and Nine hours after TIPS, the left atrial masking any severe manifestation of heart http://gut.bmj.com/ 2–4 diameter and left ventricular end diastolic failure. However, when cirrhotic patients are volume were increased (by 6% (p<0.01) challenged by pharmacological or physiologi- and 7% (p<0.01) respectively); end systolic cal stress, a syndrome termed “cirrhotic 56 volume had not changed significantly. cardiomyopathy” may become apparent. Invasive measurements showed a sharp The transjugular intrahepatic portosystemic increase in right atrial pressure (by 101%; stent shunt (TIPS) is a decompressive treat- p<0.01), mean pulmonary artery pressure ment for portal hypertension. It is based on the on September 29, 2021 by guest. Protected copyright. creation of a intrahepatic channel between the (by 92%; p<0.01), pulmonary capillary 78 wedge pressure (by 111%; p<0.01), and portal vein and the right hepatic vein. The cardiac output (8.1 (1.6) to 11.9 (2.4) sudden decompression of the splanchnic circu- l/min; p<0.01). Systemic vascular resist- lation induces a blood volume shift into the systemic vascular bed, which may be compara- ance decreased (824 (242) to 600 (265) ble with that observed during surgical shunt dyn·s·cm−5 p<0.01), and total pulmonary procedures.910This may explain the occasional resistance increased (140 (58.5) to 188 clinical observation of acute heart failure after (69.5) dyn·s·cm−5; p<0.05). Total pulmo- TIPS or a surgical portocaval shunt.11–13 nary resistance (12%; NS), cardiac output The purpose of this study was to determine Department of (1.4 l/min; p<0.05), and portal vein blood the acute and delayed eVects of a portosystemic Gastroenterology, flow (1.4 l/min; p<0.05) remained elevated Medical University stent shunt on cardiac dimensions and func- Hospital, Freiburg, for nine hours after TIPS in the subgroup. tion as well as on pulmonary and systemic cir- Germany Portoatrial pressure gradient (43%; culation in patients with alcoholic cirrhosis M Huonker p<0.05), portohepatic vascular resistance treated for variceal bleeding by TIPS. Y O Schumacher (72%; p<0.05), and systemic vascular A Ochs resistance (27%; p<0.01) were consistently S Sorichter Methods J Keul reduced. PATIENTS M Rössle Conclusions—The increase in the left atrial diameter, the pulmonary capillary We selected 17 consecutive patients (14 men Correspondence to: wedge pressure, and total pulmonary and three women, mean (SD) age 50.6 (9.9) Dr M Huonker, Department resistance observed after the TIPS proce- years) with alcoholic cirrhosis and recent of Internal Medicine, variceal bleeding, who had been in a stable cir- University of Freiburg, dure reflected diastolic dysfunction of the Hugstetterstr 55, D-79106 hyperdynamic left ventricle in patients culatory state for at least two weeks before Freiburg, Germany. with alcoholic cirrhosis. The haemo- Accepted for publication dynamic eVects of the portosystemic stent Abbreviation used in this paper: TIPS, transjugular 27 December 1998 shunt itself on the splanchnic circulation intrahepatic portosystemic stent shunt. 744 Huonker, Schumacher, Ochs, et al Table 1 Dimensions and function of the left heart in 17 patients before and nine hours output (COE) of the left ventricle were after insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) calculated using the following formulae: SV = LVEDV − LVESV Variables measured Normal range Before TIPS Nine hours after TIPS Significance E × Gut: first published as 10.1136/gut.44.5.743 on 1 May 1999. Downloaded from LVEF=SVE/LVEDV 100 HR (beats/min) 70 (8) 80.1 (14.6) 82.2 (16.1) NS CO =SV ×HR LA (mm) 33 (4.7) 41.7 (4.6) 44.3 (4.4) p<0.01 E E LVEDV (ml) 127 (18) 153.7 (29.7) 164.6 (31.9) p<0.01 All values reported were calculated from LVESV (ml) 50 (10) 54.1 (17.2) 52.9 (16.5) NS three consecutive cardiac cycles. COE (l/min) 5.4 (1) 7.89 (1.70) 9.14 (2.21) p<0.01 SVE (ml) 76 (13) 99.6 (20.7) 111.7 (21.7) p<0.01 LVEF (%) 59 (6) 65.2 (8.1) 68.3 (7.9) p<0.01 CATHETER MEASUREMENT Before TIPS implantation, a Swan-Ganz flow Values are expressed as mean (SD). directed monitoring catheter (model 93A-131, HR, heart rate; LA, left atrial diameter; LVEDV, end diastolic left ventricular volume; LVESV, end size 7F; American Edwards Laboratories, systolic left ventricular volume; COE, cardiac output; SVE, stroke volume; LVEF, left ventricular ejection fraction. Santa Ana, California, USA) was introduced via the cubital vein and placed in the TIPS implantation. Patients with non- pulmonary artery. The right atrial pressure, the alcoholic cirrhosis, active variceal bleeding, systolic, diastolic and mean pulmonary artery acute alcohol abuse, alcoholic delirium, or pressures, as well as the pulmonary capillary undergoing emergency treatment with TIPS wedge pressure were measured (Servomed were excluded. Patients with a history sugges- SMV 104 T; PPC Hellige, Freiburg, Ger- tive of, and/or electrocardiogram results or many). Cardiac output was determined using echocardiographic changes indicating, con- the thermodilution technique (Edwards Labo- comitant heart disease—for example, valvular ratories, model 9520A), and blood pressure heart diseases, ischaemic heart disease—were was measured with a mercury sphygmoma- also excluded. A further exclusion criterion nometer. The portosystemic shunt was created was ascites detectable on ultrasound, because using a balloon-expandable Palmaz stent with a the systemic circulation could be aVected by lumen diameter of 8–12 mm.7 All measure- volume changes subsequent to diuretic treat- ments were repeated immediately after this 14 15 ment or ascites absorption/formation. procedure. In a subgroup of nine randomly Drugs that may influence haemodynamic selected male patients (mean age 47.9 (10.6) parameters—for example, â-blocker agents— years, Child-Pugh grade A (n = 4), Child-Pugh were discontinued in all patients at least three grade B (n = 4), Child-Pugh grade C (n = 1)), days before the haemodynamic measure- further follow up measurements were per- ments. The severity of the cirrhosis was classi- formed at 90 minutes, three, six, and nine fied according to the Child-Pugh scale: six hours after TIPS. The portoatrial pressure patients were grade A, eight grade B, and three gradient was determined before opening of the grade C. Patients remained conscious during shunt, and 5 to 10 minutes as well as nine http://gut.bmj.com/ the entire procedure, which was performed hours after shunt procedure with the pressure without general anaesthesia or muscle relaxa- device used for the measurements in the tion. Premedication consisted of 50–100 mg pulmonary circulation. All values were derived pethidine and 2.5–5 mg midazolam given in triplicate by the same investigator. Cardiac intravenously before commencement of the output, systemic vascular resistance, and total TIPS procedure. All patients gave written pulmonary resistance were calculated as informed consent to participate in the study, described.17 which was approved by the local ethics on September 29, 2021 by guest. Protected copyright. committee. DUPLEX SONOGRAPHY In the subgroup (nine patients), portal vein blood flow velocity was measured by duplex ECHOCARDIOGRAPHY sonography (Ultramark 9; ATL, Bothell, Wash- All patients underwent an echocardiographic ington, USA). The portal vein diameter (d) was examination (2.5 MHz ultrasound system SSD determined by real time sonography before and 830, Aloka Ltd, Tokyo, Japan) before and nine nine hours after the TIPS implantation. The hours after the TIPS procedure performed by measurements were performed in triplicate. the same operator, who is familiar with cardiac Portal vein blood flow (F) was estimated from ultrasound. Simultaneously, the resting heart 2 the equation F = ðd Vmax(1/8). Portohepatic rate (HR) was determined by electrocardiogra- vascular resistance was calculated as the diVer- phy. Left atrial diameter and end systolic and ence in portoatrial pressure gradient divided by end diastolic cross sectional diameters of the the portal vein blood flow.
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