The Impact of Right Atrial Pressure on Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt

Abstract

Background and Aims: Single-center studies in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database.Approach and Results: 883 patients in ALTA multicenter TIPS database from 2010-2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure (HF). Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model non-linear relationship. Logistic regression was used to assess RAP association with secondary outcomes. Pre-TIPS RAP was independently associated with overall mortality (sHR 1.04 per mmHg, 95% CI 1.01, 1.08, P=0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction and HF. Pre-TIPS RAP was positively associated with MELD, BMI, Native American and Black race, and lower platelets. Conclusions: Pre-TIPS RAP is an independent risk factor for overall mortality following TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact.