The Toulouse algorithm identifies patients with an increased risk of cardiac decompensation only in patients with TIPS for refractory ascites

Abstract

Background and aims: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an effective, possibly life-saving, treatment for complications of portal hypertension. The pressure shift induced by the stent can lead to the development of cardiac decompensation (CD) in some cases. We investigated the incidence of CD, possible variables associated with CD and the validity of the Toulouse algorithm for risk prediction of CD post-TIPS. Method: All patients receiving TIPS for variceal bleeding (VB) or refractory ascites (RA) between 2011 and 2021 were retrospectively reviewed. A total of 106 patients (41.5% VB, 58.5% RA) had echocardiography and NT-proBNP results available and were included. Development of CD between time of TIPS placement and occurrence of liver transplantation, death or loss-to-follow-up was recorded. Competing risk regression analysis was performed to assess which baseline variables predicted occurrence of CD post-TIPS. Results: A total of 12 patients (11.3%) developed CD after a median of 11.5 days (IQR 4 to 56.5) post-TIPS. Patients who developed CD were significantly older than patients who did not (66.8 vs 59.8 years old, p = 0.045). Other baseline parameters were not significantly different, specifically active alcohol abuse, MELD score, Child-Pugh score, pressure gradients before and after TIPS, NT-proBNP and echocar-diographic parameters were similar. Multivariate regression showed age (HR 1.06, CI 1.01-1.11, p = 0.019), albumin (HR 1.10, CI 1.03-1.18, p = 0.009) and NT-proBNP (for every 100 ng/L increase HR 1.04, CI 1.00-1.07, p = 0.023) predicted CD in the RA group. No clear predictors were found in those receiving TIPS for VB. Correspondingly, the Toulouse algorithm successfully identified patients at risk for CD, however only in the RA population (zero risk 0% vs. low risk 12.5% vs. high risk 35.3% with CD; p = 0.003). CD post-TIPS was well managed with diuretics in most cases and did not lead to increased mortality in our series (1-year mortality 44.7% without CD vs. 33.3% with CD, p = 0.455). Conclusion: CD is not an infrequent complication post-TIPS occurring in 1/10 patients and mostly in the first month post-TIPS. The Toulouse algorithm can identify patients at risk of CD, though only in patients receiving TIPS for RA. Allocation to the high-risk category warrants close monitoring but should not preclude TIPS placement. SAT-093-YI Sustainable endoscopy in hepatology: quantifying the effect of applying BAVENO VII guidelines on the endoscopic carbon footprint; a multi-centred regional assessment Background and aims: With the global move towards net zero, the UK NHS has committed to reduce its carbon footprint by 80% between 2028-2033 and achieve net zero by 2040 [1]. Endoscopy is the third greatest contributing department per daily bed occupied [2], therefore re-evaluation of endoscopic indications is an important factor in achieving net zero. The Baveno VII guidelines recommend that patients with compensated cirrhosis and Fibroscan scores of less than 20 kPa and platelet counts greater than 150 × 10 9 /L are unlikely to have clinically significant varices [3], thereby negating the need for endoscopic surveillance. By applying these guidelines in conjunction with estimated energy costs from previously published data [4], we aimed to retrospectively calculate the regional endoscopic carbon footprint generated by potentially avoidable gastroscopies across four NHS trusts with access to Fibroscan. Method: In this retrospective study, data was analysed from four hospitals in the East of England. Patients undergoing primary variceal surveillance between January 2021 and October 2023 were identified and their pre-endoscopy Fibroscan results and platelet counts were assessed against the criteria listed in Baveno VII. Exclusion criteria comprised features of decompensation, previous variceal haemorrhage or portal-or splenic vein thrombosis. We defined Baveno VII non-compliance as having both Fibroscan and platelet data available but not meeting the required cut offs, or only having a platelet count available above 150 × 10 9 /L. Patients with no Fibroscan data and a platelet count less than 150 × 10 9 /L were deemed indeterminate. Use of water, mass and energy costs per procedure were estimated using previously published data. Results: 730 patient records meeting eligibility criteria were analysed. 45% (n = 330) of procedures were Baveno non-compliant. Of these 330 patients, 38% (n = 126) had pre endoscopy Fibroscan and platelet data available but did not fulfil Baveno criteria whilst 62% (n = 204) patients underwent endoscopy without Fibroscan and with platelet count above 150 × 10 9 /L. During the study dates, these 330 procedures generated approximately 37620 L of water and 78 kg of plastic waste. This totalled a carbon cost of 1657 KgCO2e. Conclusion: The exact carbon cost of a single gastroscopy has yet to be determined, however, our data which is likely to represent a significant underestimate, demonstrates that if used correctly and extrapolated on a larger scale, Baveno VII could rationalise and reduce the significant burden generated by endoscopy.