Systematic Reviews
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 21, 2025; 31(27): 107740
Published online Jul 21, 2025. doi: 10.3748/wjg.v31.i27.107740
Cardiovascular risk assessment and predictors of cardiac decompensation after transjugular intrahepatic portosystemic shunt in patients with cirrhosis
Davide R Tomassoni, Tamar Schildkraut, Vivekananda Ramachandran, Jennifer C Cooke, Rohit Sawhney
Davide R Tomassoni, Department of General Medicine, Eastern Health, Melbourne 3128, Victoria, Australia
Tamar Schildkraut, Rohit Sawhney, Department of Gastroenterology, Eastern Health, Melbourne 3128, Victoria, Australia
Vivekananda Ramachandran, Department of Radiology, Eastern Health, Melbourne 3128, Victoria, Australia
Jennifer C Cooke, Department of Cardiology, Eastern Health, Melbourne 3128, Victoria, Australia
Jennifer C Cooke, Rohit Sawhney, Eastern Health Clinical School, Monash University, Melbourne 3128, Victoria, Australia
Author contributions: Tomassoni DR was the predominant writer, performed literature search, extraction, evaluation and synthesis; Schildkraut T was secondary author, co-evaluator for literature reviewed, edited the article, provided assistance with producing figures; Ramachandran V provided radiological expertise, assistant editor; Cooke JC provided cardiology expertise, assistance with formulation of figure 4, assistant editor; Sawhney R provided research oversight, key gastroenterology consultation and major structuring of review as well as editing.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Rohit Sawhney, Associate Professor, Department of Gastroenterology, Eastern Health, 3 West, Building B, Box Hill Hospital, 8 Arnold Street, Box Hill, Melbourne 3128, Victoria, Australia. rohit.sawhney@easternhealth.org.au
Received: March 30, 2025
Revised: May 16, 2025
Accepted: July 1, 2025
Published online: July 21, 2025
Processing time: 115 Days and 10 Hours
Abstract
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.

Keywords: Portal hypertension; Transjugular intrahepatic portosystemic shunt; Pre-emptive transjugular intrahepatic portosystemic shunt; Diastolic dysfunction; N-terminal pro-B-type natriuretic peptide; Echocardiography; Left atrial strain; Multidisciplinary team; Risk stratification; Heart failure

Core Tip: Diastolic dysfunction, particularly when defined using American Society of Echocardiography criteria, consistently correlates with post-transjugular intrahepatic portosystemic shunt (TIPS) heart failure. N-terminal pro-B-type natriuretic peptide ≥ 125 pg/mL, clinical history and examination, 12-lead electrocardiography, transthoracic echocardiography can improve pre-TIPS risk stratification, optimise patient selection, and enable early cardiac optimisation. Employing additional tools, such as the heart failure with preserved ejection fraction score and left-atrial strain imaging may further characterise cardiac dysfunction however, requires further validation. Future research should clarify the role of cardiac magnetic resonance imaging and precision medicine in this cohort.