BACKGROUND Portal hypertension (PH) is a major complication of chronic liver disease and a leading cause of mortality and morbidity in patients with cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for PH-related complications, including refractory ascites, variceal bleeding, hepatic hydrothorax and Budd-Chiari syndrome. However, post-TIPS cardiac decompensation has been reported in up to 25% of patients, often due to haemodynamic shifts revealing occult cardiac dysfunction. Current approaches to pre-procedural cardiac assessment and risk stratification remain inconsistent. This systematic review examines current recommendations and emerging strategies for cardiovascular evaluation in patients with cirrhosis prior to a TIPS. AIM To identify the key predictive factors for cardiac decompensation following a TIPS in patients with cirrhosis. METHODS A systematic review of available literature, using PubMed (including MEDLINE), Embase and Cochrane databases. Results were searched comprehensively, without exclusion criteria, from inception to May 2025. Given the predominance of retrospective cohort studies, risk of bias assessment was primarily performed using the ROBINS-E tool. RESULTS Thirteen studies were included (n = 1674 patients), with a pulled mean decompensation rate of 8.8%. Due to the variability in TIPS timing, study quality and heterogeneity, a meta-analysis was not feasible, therefore results were synthesised narratively. Multiple diastolic dysfunction parameters independently and integrated through the American Society of Echocardiography guidelines demonstrated predictive value. Newly validated risk score, heart failure with preserved ejection fraction, and biomarkers such as N-terminal pro-B-type natriuretic peptide ≥ 125 pg/mL consistently highlight cardiac dysfunction amongst the literature. Our review also explored left-atrial strain imaging as well as recent advances in cardiac magnetic resonance imaging and potential genetic contributors. CONCLUSION Multiple predictors of cardiac decompensation following TIPS exist, however studies are of limited quality. Implementing reliable markers may enable early risk stratification, candidate selection and guide pre-procedural optimisation.
Tomassoni et al. (Fri,) studied this question.