What are the cardiovascular clearance requirements for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?

Cardiovascular Clearance Requirements for TIPS Procedure

Comprehensive echocardiography is mandatory before TIPS to assess cardiac function, with specific contraindications including LVEF <50%, grade III diastolic dysfunction, and moderate-to-severe portopulmonary hypertension. 1

Pre-TIPS Cardiac Evaluation Requirements

Left Ventricular Assessment

• Comprehensive echocardiography must include left ventricular ejection fraction (LVEF) measurement 1
• Left ventricular global longitudinal strain should be measured when feasible 1
• Contemporary surrogates of left ventricular diastolic function must be assessed 1
• TIPS is contraindicated if LVEF <50% 1
• TIPS is contraindicated if grade III diastolic dysfunction is present 1

Right Ventricular Assessment

• Tricuspid annular plane systolic excursion (TAPSE) measurement is required 1
• Right ventricular systolic pressure (RVSP) must be assessed 1
• Right ventricular strain should be measured if available (not standard at all centers) 1
• If RVSP >45 mmHg or TAPSE <1.6 cm, cardiology referral for right heart catheterization is required 1

Additional Cardiac Testing

• Electrocardiogram is required if tachycardia or bradycardia is noted on physical examination 1
• ECG should be performed to identify potential ischemia and/or arrhythmias 1
• Brain natriuretic peptide (BNP) or NT-proBNP may help predict post-TIPS cardiac dysfunction (BNP <40 pg/ml and NT-proBNP <125 pg/ml suggest low risk) 1

Specific Cardiac Contraindications

Cirrhotic Cardiomyopathy

• Systolic and/or diastolic dysfunction suggesting cirrhotic cardiomyopathy is a significant risk factor for post-TIPS heart failure 1
• TIPS should be avoided in patients with LVEF <50% 1
• TIPS should be avoided in patients with grade III diastolic dysfunction 1

Pulmonary Hypertension

• Extreme caution is required in patients with moderate or severe portopulmonary hypertension (mPAP >35 mmHg, PVR >3 wood units) 1
• Right atrial pressure should be measured during TIPS procedure; if >14 mmHg, right heart catheterization should be considered 1
• TIPS may precipitate right-sided heart failure in patients with pulmonary hypertension 1, 2

Valvular Disease

• Moderate or severe tricuspid regurgitation despite optimization of volume overload requires evaluation for underlying cardiopulmonary etiology 1
• Significant tricuspid regurgitation may prohibit proceeding with TIPS 1
• Careful assessment of tricuspid regurgitation etiology is necessary to determine if TIPS risk is prohibitive 1

Modifications for High Cardiac Risk Patients

• In patients with systolic/diastolic dysfunction or mild portopulmonary hypertension, consider using smaller initial stent diameter (8 mm) 1
• If desired portosystemic gradient is achieved with 8 mm stent, no additional dilatation should be pursued 1
• Post-TIPS echocardiographic surveillance at 3 months (or earlier if indicated) is recommended for patients with cardiac dysfunction or valvular disease 1

Common Pitfalls and Caveats

• Cardiac decompensation after TIPS has variable incidence from 1% at 1 week to 20% at 1 year 1
• Nonalcoholic cirrhotic patients may show transient modifications in cardiac dimension and function for 3-6 months after TIPS due to increased volume load 2
• Post-TIPS, left ventricular diastolic diameter may increase and pulmonary systolic arterial pressure may rise temporarily 2
• Hepatopulmonary syndrome (HPS) is not an indication for TIPS, though TIPS may be considered in patients with HPS who have another established indication 1

Renal Considerations

• Kidney function should be assessed prior to TIPS through serum creatinine or GFR measurement 1
• There is insufficient evidence to establish absolute renal contraindications based on creatinine level, CKD stage, or renal replacement therapy status 1