Session Title: Category 2b. CIRRHOSIS AND ITS COMPLICATIONS: b. CLINICAL ASPECTS
Presentation Date: Apr 15, 2010
RIGTH ATRIAL PRESSURE IS NOT ADEQUATE TO CALCULATE THE PORTAL PRESSURE GRADIENT IN CIRRHOSIS. A CLINICAL-HEMODYNAMIC CORRELATION STUDY
V. La Mura*, J.G. Abraldes, A. Berzigotti, E. Erice, A. Flores-Arroyo, J.C. García-Pagán, J. Bosch
Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain. *email@example.com
Background and aims: Measurement of hepatic venous pressure gradient (HVPG), the difference between “wedge” and “free” hepatic venous pressure, is the preferred method for estimating portal pressure. However it has been suggested that the gradient between wedge hepatic venous pressure and right atrial pressure (RAP) (Hepatic Atrial Pressure Gradient, HAPG), rather than the HVPG, might reflect better the hemodynamics at the varices. This study was aimed at investigating:
1) whether HAPG at baseline and during treatment with non-selective beta-blockers correlate with prognosis in patients with cirrhosis and portal hypertension;
2) to compare its prognostic value with that of HVPG, and
3) whether measuring HAPG adds significant information to measurements of HVPG.
Methods: 154 cirrhotic patients with varices with a complete hemodynamic study at baseline and during the chronic treatment for primary (n=71) or secondary (n=83) prophylaxis for bleeding. Patients were followed for up to two years, and portal hypertensive related bleeding and bleeding-free survival were analyzed.
Results: HVPG was, in all cases, equal or lower than HAPG (mean difference: 3.2 mmHg, p< 0.001). Agreement between HAPG and HVPG in patients with cirrhosis was only modest, especially in those patients with increased intra-abdominal pressure. One hundred and two patients were HVPG non-responders and 52 HVPG responders to non-selective beta-blockers, while 101 were HAPG non-responders and 53 HAPG responders (k=0.610). HVPG response showed an excellent predictive value for bleeding risk and bleeding free survival, while HAPG did not.
Conclusions: The excellent prognostic information provided by HVPG response to drug therapy is lost if HAPG response is considered. RAP should not be used for the calculation of portal pressure gradient in patients with cirrhosis.