CARDIOPULMONARY HEMODYNAMICS AND LIVER STIFFNESS CHANGES IN PREDICTING CARDIAC DECOMPENSATION AFTER TIPS: A PROSPECTIVE STUDY

BACKGROUND & AIMS Transjugular intrahepatic portosystemic shunt (TIPS) can induce significant cardiovascular distress in patients with cirrhosis. Despite its therapeutic benefits, post-TIPS cardiac decompensation (CD) remains a serious concern, with early predictive factors still incompletely characterized. The aim of this study is to identify reliable predictive factors of post-TIPS symptomatic CD (AHA stage C-D). METHODS & PATIENTS Fifty-two consecutive cirrhotic patients undergoing under-dilated TIPS between May 2022 and May 2024 at a tertiary referral center were enrolled. Indications included refractory ascites and secondary prophylaxis of variceal bleeding. Patients with hepatocellular carcinoma (HCC), severe aortic stenosis, or portal vein thrombosis were excluded. Liver stiffness (LSM) was measured by vibration-controlled transient elastography (VCTE) before, immediately after, and one month post-TIPS. Right heart catheterization (RHC) and hemodynamic measurements were performed at the same intervals. Patients were followed up to 12 months post-procedure for the occurrence of CD, defined according to AHA/ACC/HFSA guidelines. RESULTS TIPS was successfully placed in all 52 included patients, with a mean stent-graft dilation of 6 ± 1 mm. Porto-caval pressure gradient (PCPG) decreased significantly from 22 ± 5.8 mmHg pre-TIPS to 11 ± 4.1 mmHg at one month (p value < 0.001). TIPS was placed for secondary prophylaxis of variceal bleeding in 54% of patients and for refractory ascites in 46%. Median Child-Pugh score was 8 (IQR 3) and MELD-Na score 13 (IQR 7). CD developed in 21% of patients with a median onset of 3.3 months (IQR 5.8). CD was more common in older patients and those with lower hemoglobin levels. Notably, 73% of patients who developed CD had stable or increased LSM values post-TIPS, and 64% showed post-capillary pulmonary hypertension (pcPH) at one-month RHC. An LSM increase at one month and the presence of pcPH emerged as significant risk factors for CD (HR 6.42, p value 0.001; HR 6.33, p value 0.008, respectively). Accordingly, 92% of patients with one-month post-TIPS LSM reduction remained free from CD at one year. The median LSM increased by +22% in patients who developed CD, in contrast to a -23% decrease observed in those who did not (p=0.012). CONCLUSION Baseline parameters alone fail to reliably predict post-TIPS cardiac decompensation. However, dynamic evaluation of LSM and pulmonary pressures at one month provides valuable prognostic insights. Persistent or increased LSM and pcPH after TIPS are strong predictors of CD and may serve as early warning signs, supporting a risk-adapted follow-up strategy.