The Use of E/A Ratio as a Predictor of Outcome in Cirrhotic Patients Treated With Transjugular Intrahepatic Portosystemic Shunt

OBJECTIVES: The clinical significance of diastolic dysfunction in cirrhosis, a feature of cirrhotic cardiomyopathy, is unclear. The aim of this study was to assess the utility of E/A ratio, an indicator of diastolic dysfunction, to predict ascites clearance and mortality after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion. METHODS: A total of 101 cirrhotic patients who received TIPS had pre-TIPS assessments of demographics, severity of liver dysfunction (Child-Pugh and Model for End-Stage Liver Disease (MELD) scores), renal function, hemodynamics, and cardiac function (two-dimensional echocardiography). An E/A ratio of <= 1 was used to indicate diastolic dysfunction. Patients were followed-up for a mean period of 24.6 +/- 2.4 months post TIPS. RESULTS: A total of 41 patients with an E/A ratio of <= 1 (group A), and 60 patients with an E/A ratio of >1 (group B) were studied. Group A had significantly higher MELD scores (14.0 +/- 1.0 vs. 11.4 +/- 0.8; P=0.03), because of higher serum creatinine levels (107 +/- 5 vs. 86 +/- 6 mu mol/l; P<0.01). There was no difference in pre-TIPS systemic hemodynamics, systolic function, or portal pressure between the two groups. After TIPS, more patients in group B had ascites clearance (log rank, P = 0.038), and the same patients had a higher probability of survival (log rank, P = 0.046). There were three post-TIPS cardiac deaths in group A only. A multivariate analysis showed that an E/A of ratio <= 1 was predictive of slow ascites clearance (hazard ratio = 7.3, 95% confidence interval = 1.3-40.7, P = 0.021) and death after TIPS (hazard ratio=4.7, 95% confidence interval=1.1-20.2, P = 0.035). CONCLUSIONS: Diastolic dysfunction, indicated by reduced E/A ratio, is prevalent in advanced cirrhosis and is associated with reduced ascites clearance and increased mortality post TIPS, possibly related to worsening of hemodynamic dysfunction in the post-TIPS period.