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265 THE EFFECT OF CIRRHOTIC CARDIOMYOPATHY ON THE POST-TIPS OUTCOME OF PATIENTS TREATED FOR COMPLICATIONS OF PORTAL HYPERTENSION R Rabie1, M Cazzaniga2, F Salerno2, F Wong1 Cirrhotic Cardiomyopathy (CCM) is a recently recognized entity comprised of diastolic dysfunction, systolic incompetence under conditions of stress, and electrophysiological abnormalities observed in patients with cirrhosis. Its clinical significance is still unclear.
1The University of Toronto, Toronto, Ontario; 2The University of Milan, Milan, Italy
AIM: To assess whether the presence of diastolic dysfunction pre-TIPS is related to the morbidity and mortality after TIPS.
METHODS: All patients at 2 tertiary care centres in Toronto and Milan who received a TIPS for complications of portal hypertension from 1997 to 2005 had pre-TIPS assessment of demographics, severity of liver disease (Child-Pugh & MELD), hemodynamics, and cardiac function (2D Echocardiography). Diastolic dysfunction was defined as an E/A ratio (E= rapid ventricular filling, A=contribution of atrial systole to ventricular filling) of <= 1. All patients were followed at 3 monthly intervals post-TIPS for assessment of clinical outcome including survival.
RESULTS: 101 cirrhotic TIPS patients consisting of 41 patients with E/A ratio <= 1 (Group A, 30 males, 11 females, mean age=61.4 ± 1.2 years, p<0.01 vs. Group B), and 60 patients with E/A > 1 (Group B, 43 males, 17 females, mean age=54.4 ± 1.3 years) were assessed. Both groups had similar Child-Pugh scores, but Group A had higher MELD scores (14.0 ± 1.0 vs 11.4 ± 0.8, p=0.03), due to higher serum creatinine (107 ± 5µmol/L vs 86.6µmol/L, p<0.01). There was no difference in pre-TIPS systemic hemodynamics, systolic function or portal pressures between the 2 groups. Group B had significantly better clearance of ascites (67.6% vs 45.8%, p< 0.01) and a higher probability of survival at 6, 12 and 24 months (85%, 81% and 77% respectively) than Group A (66%, 61% and 46% respectively) (log rank, p=0.0046). Multivariate analysis identified the presence of diastolic dysfunction as an independent predictor of mortality post-TIPS with an odds ratio of 4 (1.1-14.4).
CONCLUSIONS: Diastolic dysfunction is prevalent in advanced cirrhosis, and is associated with older age and renal impairment. It contributes to reduced ascites clearance and serves as an independent predictor of mortality post-TIPS. The latter may be related to the inability of these patients to maintain hemodynamic stability in the post-TIPS period.