[Hemodynamic response in cirrhotic patients with transjugular intrahepatic portosystemic shunt].

Objective: To discuss the effects of transjugular intrahepatic portosystemic shunt (TIPS) procedure on hemodynamics in cirrhotic patients. Methods: A total of 23 cirrhotic patients for TIPS insertion were enrolled from January 2018 to October 2018. Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), transthoracic echocardiography and non-invasive cardiac output measurement based on impedance cardiogram were carried out before and 24h, 1 month, 6 months after TIPS in order to observe cardiac function and hemodynamic changes after TIPS. Results: Significant increases in right atrial area [(17.2±4.0) cm(2) vs. (15.0±3.4) cm(2), P<0.05], right ventricular area [(15.1±3.8) cm(2) vs. (13.7±3.5) cm(2), P<0.05] and left ventricular volume [(97.4±21.5) ml vs. (91.1±22.7) ml, P<0.05] were observed 24 h after TIPS. These changes were accompanied with significant reduction in collapsible index of inferior vena cava [(20.7± 8.1)% vs. (28.6±11.3)%, P<0.01] and elevation in pulmonary arterial systolic pressure [(36.0±8.4) mmHg (1 mmHg=0.133 kPa) vs. (31.8±5.4) mmHg, P<0.01]. There also existed significantly elevated serum NT-proBNP [(551.2±325.1) ng/L vs. (124.2±94.4) ng/L, P<0.01], cardiac output [(5.82±0.96) L/min vs. (5.12±1.28) L/min, P<0.01], cardiac index [(3.47±0.64) L·min(-1)·m(-2) vs. (3.05±0.78) L·min(-1)·m(-2), P<0.01], early diastolic filling rate [(59.0±14.3)% vs. (54.5±11.0)%, P<0.05], and reduced systemic vascular resistance index (SVRi) [(1 798.4±357.3) dyne·s·cm(-5)·m(-2) vs. (2 195.7±508.7) dyne·s·cm(-5)·m(-2), P<0.01] 24 h after TIPS. At the end of 6-month follow-up, all these parameters, but not SVRi, returned towards baseline values. Moreover, peak early to late diastolic tissue velocity ratio at the level of lateral mitral annulus (E'/A') was significantly higher at the end of 6-month follow-up than that at baseline (1.06±0.32 vs. 0.90±0.45, P<0.05). Neither the right ventricular fractional area changes nor the left ventricular ejection fractions during the follow-up period were different from those at baseline (P>0.05). Conclusion: Cirrhotic patients who had no cardiovascular pathologies had adequate adaptation and good compensation ability to reach a new hemodynamic homeostasis for the increased volume load after TIPS insertion.目的： 探讨肝硬化患者经颈静脉肝内门体分流（TIPS）术对心功能和血流动力学的影响。 方法： 收集2018年1—10月于复旦大学附属中山医院拟行TIPS手术的失代偿肝硬化患者共23例，术前行血清N末端B型利钠肽原（NT-proBNP）、经胸超声心动图检查，心阻抗图法行无创心输出量监测。术后24 h、1个月、6个月对所有患者进行随访，观察TIPS术后心脏功能及血流动力学指标变化特点和趋势。 结果： 与术前比，TIPS术后24 h，右心房面积[（17.2±4.0）cm(2)比（15.0±3.4）cm(2)，P<0.05]、右心室面积[（15.1±3.8）cm(2)比（13.7±3.5）cm(2)，P<0.05]和左心室容积[（97.4±21.5）ml比（91.1±22.7）ml，P<0.05]显著增加，下腔静脉塌陷指数（IVC-CI）显著降低[（20.7±8.1）%比（28.6±11.3）%，P<0.01]，肺动脉收缩压显著升高[（36.0±8.4）mmHg（1 mmHg=0.133 kPa）比（31.8±5.4）mmHg，P<0.01]；血清NT-proBNP[（551.2±325.1）ng/L比（124.2±94.4）ng/L，P<0.01]、心输出量[（5.82±0.96）L/min比（5.12±1.28）L/min，P<0.01]、心指数[（3.47±0.64）L·min(-1)·m(-2)比（3.05±0.78）L·min(-1)·m(-2)，P<0.01]、舒张早期充盈率[（59.0±14.3）%比（54.5±11.0）%，P<0.05]均显著升高，外周血管阻力指数显著下降[（1 798.4±357.3）dyne·s·cm(-5)·m(-2)比（2 195.7±508.7）dyne·s·cm(-5)·m(-2)，P<0.01]。随访至术后6个月，除外周血管阻力指数，其余指标均逐步恢复至术前水平。TIPS术后6个月，二尖瓣环侧壁组织舒张早期和心房收缩期充盈峰值速度比值（E′/A′）较术前显著提高（1.06±0.32比0.90±0.45，P<0.05）。整个随访过程中，右心室面积变化分数、左心室射血分数较术前均无显著变化（P>0.05）。 结论： 心脏对TIPS术后容量负荷增加具有较好适应和代偿能力，以达到新的血流动力学稳态。.