Letter: cardiovascular complications in patients with transjugular intrahepatic portosystemic shunt – the necessity for regular cardiac surveillance

Sirs, I read with great interest the article by Wannhoff et al. and their response to the editorial.1, 2 The authors retrospectively investigated the influence of transjugular intrahepatic portosystemic shunt (TIPSS) on cardiac function in patients with liver cirrhosis, and they concluded a need for regular cardiac surveillance in patients with TIPSS. However, I think that the current evidence does not support this conclusion. By inducing a sudden increase in preload, TIPSS may deteriorate cardiac dysfunction of patients with liver cirrhosis. However, most of the alterations were transient and seemed to normalise within months.3 With proper screening for serious cardiac and pulmonary diseases prior to the procedure, fatal cardiovascular complications such as heart failure and cardiac arrest occur in very few cases.4, 5 Cardiovascular related death was also uncommon in long-term follow up.4, 6 This result was also confirmed in the present study that found only a slight increase in the diameter of left atrium and ventricle, while the diastolic and systolic functions were unchanged or improved to some extent. Furthermore, whether cardiac function influences prognosis is still controversial. In contrast to two previous studies that reported diastolic dysfunction (E/A < 1) was associated with poor survival, Wannhoff et al. did not find an association between cardiac diastolic function and prognosis.6, 7 The variant indices used in each study may help explain the inconsistent findings. In fact E/A is influenced by multiple factors such as age and preload.8 Finally and most importantly, there currently is no specific treatment of asymptomatic cirrhotic cardiomyopathy.9 Prevalence of pulmonary hypertension, especially portopulmonary hypertension (1.9%) reported in this article, was at a relatively low level, which agrees with results from the literature.5 As stated in the editorial, whether TIPSS can increase incidence of pulmonary hypertension still needs further confirmation.10 Based on current evidence, I think it is important to summarise the characteristics of these patients and seek out patients at high risk rather than conduct regular cardiac surveillance in all patients. In summary, symptomatic cardiovascular diseases are rare in cirrhotic patients with TIPSS. The role of cardiac dysfunction in prognosis of TIPSS patients remains controversial. When necessary, practitioners should perform cardiac surveillance. Additional studies are warranted to investigate the role of cardiac condition in cirrhotic patients with TIPSS. Declaration of personal and funding interests: None.