Cardiovascular Clearance Requirements for TIPS Procedure

Pre-TIPS Cardiac Evaluation Requirements

• Comprehensive echocardiography must include left ventricular ejection fraction (LVEF) measurement, according to the American Gastroenterological Association, to assess cardiac function in patients undergoing TIPS procedure 1
• Left ventricular global longitudinal strain should be measured when feasible, as recommended by the American Gastroenterological Association, to evaluate left ventricular function in patients undergoing TIPS procedure 1
• Contemporary surrogates of left ventricular diastolic function must be assessed, as suggested by the American Gastroenterological Association, to evaluate diastolic function in patients undergoing TIPS procedure 1
• TIPS is contraindicated if LVEF <50%, as stated by the American Association for the Study of Liver Diseases, due to increased risk of cardiac complications 3
• TIPS is contraindicated if grade III diastolic dysfunction is present, as stated by the American Association for the Study of Liver Diseases, due to increased risk of cardiac complications 3
• Tricuspid annular plane systolic excursion (TAPSE) measurement is required, as recommended by the American Society of Echocardiography, to assess right ventricular function in patients undergoing TIPS procedure 1
• Right ventricular systolic pressure (RVSP) must be assessed, as recommended by the American Society of Echocardiography, to evaluate right ventricular function in patients undergoing TIPS procedure 1
• If RVSP >45 mmHg or TAPSE <1.6 cm, cardiology referral for right heart catheterization is required, as recommended by the American Heart Association and the European Association for the Study of the Liver 1, 2
• Electrocardiogram is required if tachycardia or bradycardia is noted on physical examination, as recommended by the American College of Cardiology, to evaluate cardiac rhythm in patients undergoing TIPS procedure 1
• ECG should be performed to identify potential ischemia and/or arrhythmias, as recommended by the European Society of Cardiology, to evaluate cardiac rhythm in patients undergoing TIPS procedure 2
• Brain natriuretic peptide (BNP) or NT-proBNP may help predict post-TIPS cardiac dysfunction, as suggested by the American Heart Association, with BNP <40 pg/ml and NT-proBNP <125 pg/ml suggesting low risk 2

Specific Cardiac Contraindications

• Systolic and/or diastolic dysfunction suggesting cirrhotic cardiomyopathy is a significant risk factor for post-TIPS heart failure, as stated by the American Association for the Study of Liver Diseases 1
• Extreme caution is required in patients with moderate or severe portopulmonary hypertension, as recommended by the European Respiratory Society, with mPAP >35 mmHg, PVR >3 wood units 2, 4
• Right atrial pressure should be measured during TIPS procedure; if >14 mmHg, right heart catheterization should be considered, as recommended by the American Heart Association 4
• TIPS may precipitate right-sided heart failure in patients with pulmonary hypertension, as stated by the American Thoracic Society 4

Modifications for High Cardiac Risk Patients

• In patients with systolic/diastolic dysfunction or mild portopulmonary hypertension, consider using smaller initial stent diameter (8 mm), as recommended by the Society of Interventional Radiology 6
• Post-TIPS echocardiographic surveillance at 3 months (or earlier if indicated) is recommended for patients with cardiac dysfunction or valvular disease, as recommended by the American Society of Echocardiography 7

Common Pitfalls and Caveats

• Cardiac decompensation after TIPS has variable incidence from 1% at 1 week to 20% at 1 year, as reported by the Journal of Hepatology 2
• Hepatopulmonary syndrome (HPS) is not an indication for TIPS, though TIPS may be considered in patients with HPS who have another established indication, as stated by the American Thoracic Society 8

Renal Considerations

• Kidney function should be assessed prior to TIPS through serum creatinine or GFR measurement, as recommended by the National Kidney Foundation 9
• There is insufficient evidence to establish absolute renal contraindications based on creatinine level, CKD stage, or renal replacement therapy status, as stated by the American Society of Nephrology 9