The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt

OBJECTIVES:The clinical significance of diastolic dysfunction in cirrhosis, a feature of cirrhotic cardiomyopathy, is unclear. The aim of this study was to assess the utility of E/A ratio, an indicator of diastolic dysfunction, to predict ascites clearance and mortality after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion.METHODS:A total of 101 cirrhotic patients who received TIPS had pre-TIPS assessments of demographics, severity of liver dysfunction (Child-Pugh and Model for End-Stage Liver Disease (MELD) scores), renal function, hemodynamics, and cardiac function (two-dimensional echocardiography). An E/A ratio of 1 was used to indicate diastolic dysfunction. Patients were followed-up for a mean period of 24.62.4 months post TIPS.RESULTS:A total of 41 patients with an E/A ratio of 1 (group A), and 60 patients with an E/A ratio of 1 (group B) were studied. Group A had significantly higher MELD scores (14.01.0 vs. 11.40.8; P0.03), because of higher serum creatinine levels (1075 vs. 866 mol/l; P0.01). There was no difference in pre-TIPS systemic hemodynamics, systolic function, or portal pressure between the two groups. After TIPS, more patients in group B had ascites clearance (log rank, P0.038), and the same patients had a higher probability of survival (log rank, P0.046). There were three post-TIPS cardiac deaths in group A only. A multivariate analysis showed that an E/A of ratio 1 was predictive of slow ascites clearance (hazard ratio7.3, 95% confidence interval1.3-40.7, P0.021) and death after TIPS (hazard ratio4.7, 95% confidence interval1.1-20.2, P0.035).CONCLUSIONS:Diastolic dysfunction, indicated by reduced E/A ratio, is prevalent in advanced cirrhosis and is associated with reduced ascites clearance and increased mortality post TIPS, possibly related to worsening of hemodynamic dysfunction in the post-TIPS period.