Hepatic venous pressure gradient: Inaccurately estimates portal venous pressure gradient in alcoholic cirrhosis and portal hypertension

BACKGROUND Portal hypertension(PHT)in patients with alcoholic cirrhosis causes a range of clinical symptoms,including gastroesophageal varices and ascites.The hepatic venous pressure gradient(HVPG),which is easier to measure,has replaced the portal venous pressure gradient(PPG)as the gold standard for diagnosing PHT in clinical practice.Therefore,attention should be paid to the correlation between HVPG and PPG.METHODS Between January 2017 and June 2020,134 patients with alcoholic cirrhosis and PHT who met the inclusion criteria underwent various pressure measurements during transjugular intrahepatic portosystemic shunt procedures.Correlations were assessed using Pearson’s correlation coefficient to estimate the correlation coefficient(r)and determination coefficient(R^(2)).Bland-Altman plots were constructed to further analyze the agreement between the measurements.Disagreements were analyzed using paired t tests,and P values<0.05 were considered statistically significant.RESULTS In this study,the correlation coefficient(r)and determination coefficient(R2)between HVPG and PPG were 0.201 and 0.040,respectively(P=0.020).In the 108 patients with no collateral branch,the average wedged hepatic venous pressure was lower than the average portal venous pressure(30.65±8.17 vs.33.25±6.60 mmHg,P=0.002).Hepatic collaterals were identified in 26 cases with balloon occlusion hepatic venography(19.4%),while the average PPG was significantly higher than the average HVPG(25.94±7.42 mmHg vs 9.86±7.44 mmHg;P<0.001).The differences between HVPG and PPG<5 mmHg in the collateral vs no collateral branch groups were three cases(11.54%)and 44 cases(40.74%),respectively.CONCLUSION In most patients,HVPG cannot accurately represent PPG.The formation of hepatic collaterals is a vital reason for the strong underestimation of HVPG.

Pre-transjugular-intrahepatic-portosystemic-shunt measurement of hepatic venous pressure gradient and its clinical application: A comparison study

BACKGROUND It is controversial whether transjugular intrahepatic portosystemic shunt(TIPS)placement can improve long-term survival.AIM To assess whether TIPS placement improves survival in patients with hepaticvenous-pressure-gradient(HVPG)≥16 mmHg,based on HVPG-related risk stratification.METHODS Consecutive variceal bleeding patients treated with endoscopic therapy+nonselectiveβ-blockers(NSBBs)or covered TIPS placement were retrospectively enrolled between January 2013 and December 2019.HVPG measurements were performed before therapy.The primary outcome was transplant-free survival;secondary endpoints were rebleeding and overt hepatic ence-phalopathy(OHE).RESULTS A total of 184 patients were analyzed(mean age,55.27 years±13.86,107 males;102 in the EVL+NSBB group,82 in the covered TIPS group).Based on the HVPG guided risk stratification,70 patients had HVPG<16 mmHg,and 114 patients had HVPG≥16 mmHg.The median follow-up time of the cohort was 49.5 mo.There was no significant difference in transplant-free survival between the two treatment groups overall(hazard ratio[HR],0.61;95%confidence interval[CI]:0.35-1.05;P=0.07).In the high-HVPG tier,transplant-free survival was higher in the TIPS group(HR,0.44;95%CI:0.23-0.85;P=0.004).In the low-HVPG tier,transplantfree survival after the two treatments was similar(HR,0.86;95%CI:0.33-0.23;P=0.74).Covered TIPS placement decreased the rate of rebleeding independent of the HVPG tier(P<0.001).The difference in OHE between the two groups was not statistically significant(P=0.09;P=0.48).CONCLUSION TIPS placement can effectively improve transplant-free survival when the HVPG is greater than 16 mmHg.

Accuracy of Mean Value of Central Venous Pressure from Monitor Digital Display: Influence of Amplitude of Central Venous Pressure during Respiration

Background A simple measurement of central venous pressure(CVP)-mean by the digital monitor display has become increasingly popular.However,the agreement between CVP-mean and CVP-end(a standard method of CVP measurement by analyzing the waveform at end-expiration)is not well determined.This study was designed to identify the relationship between CVP-mean and CVP-end in critically ill patients and to introduce a new parameter of CVP amplitude(ΔCVP=CVPmax-CVPmin)during the respiratory period to identify the agreement/disagreement between CVP-mean and CVP-end.Methods In total,291 patients were included in the study.CVP-mean and CVP-end were obtained simultaneously from each patient.CVP measurement difference(|CVP-mean-CVP-end|)was defined as the difference between CVP-mean and CVP-end.TheΔCVP was calculated as the difference between the peak(CVPmax)and the nadir value(CVPmin)during the respiratory cycle,which was automatically recorded on the monitor screen.Subjects with|CVP-mean-CVP-end|≥2 mm Hg were divided into the inconsistent group,while subjects with|CVP-mean-CVP-end|2 mm Hg were divided into the consistent group.ResultsΔCVP was significantly higher in the inconsistent group[7.17(2.77)vs.5.24(2.18),P0.001]than that in the consistent group.There was a significantly positive relationship betweenΔCVP and|CVP-mean-CVP-end|(r=0.283,P 0.0001).Bland-Altman plot showed the bias was-0.61 mm Hg with a wide 95%limit of agreement(-3.34,2.10)of CVP-end and CVP-mean.The area under the receiver operating characteristic curves(AUC)ofΔCVP for predicting|CVP-mean-CVP-end|≥2 mm Hg was 0.709.With a high diagnostic specificity,usingΔCVP3 to detect|CVP-mean-CVP-end|lower than 2mm Hg(consistent measurement)resulted in a sensitivity of 22.37%and a specificity of 93.06%.UsingΔCVP8 to detect|CVP-mean-CVPend|8 mm Hg(inconsistent measurement)resulted in a sensitivity of 31.94%and a specificity of 91.32%.Conclusions CVP-end and CVP-mean have statistical discrepancies in specific clinical scenarios.ΔCVP during the respiratory period is related to the variation of the two CVP methods.A highΔCVP indicates a poor agreement between these two methods,whereas a lowΔCVP indicates a good agreement between these two methods.

Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma

BACKGROUND:Low central venous pressure(CVP) affects hemodynamic stability and tissue perfusion.This prospective study aimed to evaluate the optimal CVP during partial hepatectomy for hepatocellular carcinoma(HCC).METHODS:Ninety-seven patients who underwent partial hepatectomy for HCC had their CVP controlled at a level of 0 to 5 mmHg during hepatic parenchymal transection.The systolic blood pressure(SBP) was maintained,if possible,at 90 mmHg or higher.Hepatitis B surface antigen was positive in 90 patients(92.8%) and cirrhosis in 84 patients(86.6%).Pringle maneuver was used routinely in these patients with clamp/unclamp cycles of 15/5 minutes.The average clamp time was 21.4±8.0 minutes.These patients were divided into 5 groups based on the CVP:group A:0-1 mmHg;B:1.1-2 mmHg;C:2.1-3 mmHg;D:3.1-4 mmHg and E:4.1-5 mmHg.The blood loss per transection area during hepatic parenchymal transection and the arterial blood gas before and after liver transection were analyzed.RESULTS:With active fluid load,a constant SBP ≥90 mmHg which was considered as optimal was maintained in 18.6% in group A(95% CI:10.8%-26.3%);39.2% in group B(95% CI:29.5%-48.9%);72.2% in group C(95% CI:63.2%-81.1%);89.7% in group D(95% CI:83.6%-95.7%);and 100% in group E(95% CI:100%-100%).The blood loss per transection area during hepatic parenchymal transection decreased with a decrease in CVP.Compared to groups D and E,blood loss in groups A,B and C was significantly less(analysis of variance test,P【0.05).Compared with the baseline,the blood oxygenation decreased significantly when the CVP was reduced.Base excess and HCO 3-in groups A and B were significantly decreased compared with those in groups C,D and E(P【0.05).CONCLUSION:In consideration of blood loss,SBP,base excess and HCO 3-,a CVP of 2.1-3 mmHg was optimal in patients undergoing partial hepatectomy for HCC.

Hemodynamics and oxygen transport dynamics during hepatic resection at different central venous pressures in a pig model

BACKGROUND: Although low central venous pressure (CVP) has been used to minimize blood loss during hepatectomy the impact of variations of CVP on the rate of blood loss and on the perfusion of end-organs has not been evaluated This animal study aimed to evaluate the hemodynamics and oxygen transport changes during hepatic resection at different CVP levels. METHODS: Forty-eight anesthetized Bama miniature pigs were divided into 8 groups with CVP during hepatic resection controlled at 0 to <1, 1 to <2, 2 to <3, 3 to <4, 4 to <5, 5 to <6, 6 to <7, and 7 to <8 cmH 2 O. Intergroup comparisons were made for hemodynamic parameters, oxygen transport dynamics, and the rate of blood loss. RESULTS: The rate of blood loss and the hepatic venous pressure during hepatic resection were almost linearly related to the CVP. A significant drop in the mean arterial pressure cardiac output, and cardiac index occurred between CVP ≥2 and <2 cmH 2 O. Oxygen delivery (DO 2 ), oxygen consumption (VO 2 ) and oxygen extraction ratio (ERO 2 ) remained relatively constant between CVPs of 2 to <8 cmH 2 O. There was a significant drop in DO 2 when the CVP was <2 cmH 2 O. There was also a significant drop in VO 2 and ExO 2 when the CVP was <1 cmH 2 O.CONCLUSION: The optimal CVP for hepatic resection is 2to 3 cmH2O.

Computed tomography perfusion in liver and spleen for hepatitis B virus-related portal hypertension:A correlation study with hepatic venous pressure gradient

BACKGROUND Hepatic venous pressure gradient(HVPG)is the gold standard for diagnosis of portal hypertension(PH).However,its use can be limited because it is an invasive procedure.Therefore,it is necessary to explore a non-invasive method to assess PH.AIM To investigate the correlation of computed tomography(CT)perfusion of the liver with HVPG and Child-Pugh score in hepatitis B virus(HBV)-related PH.METHODS Twenty-eight patients(4 female,24 male)with gastroesophageal variceal bleeding induced by HBV-related PH were recruited in our study.All patients received CT perfusion of the liver before transjugular intrahepatic portosystemic stent-shunt(TIPS)therapy.Quantitative parameters of CT perfusion of the liver,including liver blood flow(LBF),liver blood volume(LBV),hepatic artery fraction,splenic blood flow and splenic blood volume were measured.HVPG was recorded during TIPS therapy.Correlation of liver perfusion with Child-Pugh score and HVPG were analyzed,and the receiver operating characteristic curve was analyzed.Based on HVPG(>12 mmHg vs≤12 mmHg),patients were divided into moderate and severe groups,and all parameters were compared.RESULTS Based on HVPG,18 patients were classified into the moderate group and 10 patients were classified into the severe group.The Child-Pugh score,HVPG,LBF and LBV were significantly higher in the moderate group compared to the severe group(all P<0.05).LBF and LBV were negatively associated with HVPG(r=-0.473,P<0.05 and r=-0.503,P<0.01,respectively),whereas splenic blood flow was positively associated with hepatic artery fraction(r=0.434,P<0.05).LBV was negatively correlated with Child-Pugh score.Child-Pugh score was not related to HVPG.Using a cutoff value of 17.85 mL/min/100 g for LBV,the sensitivity and specificity of HVPG≥12 mmHg for diagnosis were 80%and 89%,respectively.CONCLUSION LBV and LBF were negatively correlated with HVPG and Child-Pugh scores.CT perfusion imaging is a potential non-invasive quantitative predictor for PH in HBV-related liver cirrhosis.

Correlation of Inferior Vena Cava Respiratory Variability Index with Central Venous Pressure and Hemodynamic Parameters in Ventilated Pigs with Septic Shock

Septic shock is a common critical condition, for which effective early fluid resuscitation is the therapeutic focus. According to the 2008 international guidelines for management of severe sepsis and septic shock, resuscitation should achieve a central venous pressure （CVP） of 8-12 mmHg within the first 6 h. However, it is still uncertain about the sensitivity and specificity of CVP in reflecting the cardiac preload. Ultrasonography is a simple, rapid, non-invasive, and repeatable method for the measurement of sensitivity and specificity of CVP and has thus gradually attracted the increasing attention of physicians. It was reported that ultrasonography can show the inferior vena cava diameter, respiratory variability index, and blood volume in patients with sepsis or heart failure.

Effect of positive end-expiratory pressure ventilation on central venous pressure and intraoperative blood loss in patients undergoing laparoscopic hepatectomy

Objective:Tto investigate the effects of positive end-expiratory pressure(PEEP)ventilation on central venous pressure(CVP)and intraoperative blood loss in patients undergoing laparoscopic hepatectomy.Methods:46 cases of patients undergoing laparoscopic hepatectomy,25 cases of male,female 21 cases,ASAⅠ~Ⅲlevel,were randomly divided into two groups.In group A tidal volume was set to 6 ml/kg(Predicted Body Weight,PBW)and PEEP was set to 0 cmH2O.The tidal volume of group B was set as group A,PEEP was set to 8 cmH2O.CVP,MAP,and Ppeak were recorded in the supine position after intubation(T0),supine position after pneumoperitoneal(T1),anti-trendelenberg position after pneumoperitoneal(T2),supine position after surgery(T3),and Ddyn was calculated.The amount of nitroglycerin and the amount of blood loss were recorded.Results:Compared with group A,the CVP of group B was significantly increased at T1 and T2(P<0.05).Compared to T2 with T1 in group A and group B,CVP was decreased significantly(P<0.05).At T3,Cdyn in group B was significantly higher than that in group A(P<0.05).The amount of nitroglycerin in group B was significantly higher than that in group A(P<0.05).There was no significant difference in intraoperative fluid rehydration and blood loss between the two groups(P>0.05).Conclusion:PEEP with 8cmH2O can improve Ddyn in patients undergoing laparoscopic hepatectomy,but increased CVP.It requires more use of controlled low central venous pressure techniques to reduce intraoperative blood loss.

Ultrasound based estimate of central venous pressure:Are we any closer?

Central venous pressure(CVP)serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume,venous compliance,cardiac output,and orthostasis.Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance.Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances.Elevated CVP can lead to fluid accumulation in the interstitial space,impairing venous return and reducing cardiac preload.While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate,they carry risk of complications and their usage has not shown clinical improvement.Ultrasound-based assessment of the internal jugular vein(IJV)offers real-time,non-invasive measurement of static and dynamic parameters for estimating CVP.IJV parameters,including diameter and ratio,has demonstrated good correlation with CVP.Despite significant advancements in non-invasive CVP measurement,a reliable tool is yet to be found.Present methods can offer reasonable guidance in assessing CVP,provided their limitations are acknowledged.

Association of different central venous pressure levels with outcome of living-donor liver transplantation in children under 12 years

Background Pediatric liver transplantation is an important modality for treating biliary atresia.The overall survival(OS)rate of pediatric liver transplantation has significantly improved compared with that of 20 years ago,but it is still unsatisfactory.The anesthesia strategy of maintaining low central venous pressure(CVP)has shown a positive effect on prognosis in adult liver transplantation.However,this relationship remains unclear in pediatric liver transplantation.Thus,this study was conducted to review the data of pediatric living-donor liver transplantation to analyze the associations of different CVP levels with the prognosis of recipients.Methods This was a retrospective study and the patients were divided into two groups according to CVP levels after abdominal closure:low CVP(LCVP)(≤10 cmH2O,n=470)and high CVP(HCVP)(>10 cmH2O,n=242).The primary outcome measured in the study was the overall survival rate.The secondary outcomes included the duration of mechanical ventilation in the intensive care unit(ICU),length of stay in the ICU,and postoperative stay in the hospital.Patient demographic and perioperative data were collected and compared between the two groups.Kaplan-Meier curves were constructed to determine the associations of different CVP levels with the survival rate.Results In the study,712 patients,including 470 in the LCVP group and 242 in the HCVP group,were enrolled.After propensity score matching,212 pairs remained in the group.The LCVP group showed a higher overall survival rate than the HCVP group in the Kaplan-Meier curves and multivariate Cox regression analyses(P=0.018),and the HCVP group had a hazard ratio of 2.445(95%confidence interval,1.163–5.140).Conclusion This study confirmed that a low-CVP level at the end of surgery is associated with improved overall survival and a shorter length of hospital stay.

Correlation between Glasgow Coma Scale with central venous pressure and near-infrared spectroscopy in patients with acquired brain injury in the intensive care unit of Adam Malik Hospital Medan

Background:Acquired brain injury(ABI)is caused by trauma or nontrauma to the brain after birth.Increased intracranial pressure in patients with traumatic or nontraumatic brain injury affects the cerebral perfusion pressure.After traumatic brain injury,there is an increase in air content in the brain and an increase in volume of blood flow to the brain,which can cause increased intracranial pressure,herniation of brain tissue,impaired cerebral perfusion,and brain damage.Most patients with traumatic brain injury die from uncontrolled increases in intracranial pressure.Near-infrared spectroscopy(NIRS)and central venous pressure(CVP)monitoring are also associated with cerebral perfusion.This study aimed to determine the relationship between the Glasgow Coma Scale(GCS)scores and CVP and NIRS values in patients with ABI.Methods:This prospective analytical study used a cross-sectional design to compareGCS scores with CVP and NIRS values in patients with traumatic and nontraumatic brain injury in the intensive care unit(ICU)of Haji Adam Malik Hospital Medan.GCS,CVP,and NIRS descriptive data in patients with brain injury were presented in terms of mean and standard deviation if the data were normally distributed,or median(interquartile range)values if the data were not normally distributed.The relationship between GCS scores and CVP and NIRS values was assessed using the Pearson correlation test if the data were normally distributed,or the Spearman test if the data were not normally distributed.Results:In this study,the mean GCS score and CVP values were 7.04±2.69 and 5.63±25.82 mmHg,respectively.The right tissue oxygen saturation(StO2)was 55.61%±18.72%,and the left StO2 was 57.57%±17.48%with normally distributed data.There was no correlation between GCS scores and CVP values(P=0.829),and no correlation between moderate GCS scores and right and left StO2(P=0.343;P=0.121);however,there was a significantly strong positive correlation between severe GCS scores and right and left StO2(P=0.028,r=0.656;P=0.005,r=0.777).Conclusion:There was no significant correlation between GCS scores and CVP values,and no correlation between moderate GCS scores and NIRS values;however,there was a significantly strong positive correlation between severe GCS scores and NIRS values in patients with ABI at the ICU of Haji Adam Malik Hospital Medan.

Optimization of central venous pressure during the perioperative period is associated with improved prognosis of high-risk operation patients

Background:While central venous pressure(CVP)measurement is used to guide fluid management for high-risk surgical patients during the perioperative period,its relationship to patient prognosis is unknown.Methods:This single-center,retrospective observational study enrolled patients undergoing high-risk surgery from February 1,2014 to November 31,2020,who were admitted to the surgical intensive care unit(ICU)directly after surgery.Patients were divided into the following three groups according to the first CVP measurement(CVP1)after admission to the ICU:low,CVP1<8 mmHg;moderate,8 mmHg≤CVP1≤12 mmHg;and high,CVP1>12 mmHg.Perioperative fluid balance,28-day mortality,length of stay in the ICU,and hospitalization and surgical complications were compared across groups.Results:Of the 775 high-risk surgical patients enrolled in the study,228 were included in the analysis.Median(interquartile range)positive fluid balance during surgery was lowest in the low CVP1 group and highest in the high CVP1 group(low CVP1:770[410,1205]mL;moderate CVP1:1070[685,1500]mL;high CVP1:1570[1008,2000]mL;all P<0.001).The volume of positive fluid balance during the perioperative period was correlated with CVP1(r=0.336,P<0.001).The partial arterial pressure of oxygen(PaO 2)/fraction of inspired oxygen(FiO 2)ratio was significantly lower in the high CVP1 group than in the low and moderate CVP1 groups(low CVP1:400.0[299.5,443.3]mmHg;moderate CVP1:362.5[330.0,434.9]mmHg;high CVP1:335.3[254.0,363.5]mmHg;all P<0.001).The incidence of postoperative acute kidney injury(AKI)was lowest in the moderate CVP1 group(low CVP1:9.2%;moderate CVP1:2.7%;high CVP1:16.0%;P=0.007).The proportion of patients receiving renal replacement therapy was highest in the high CVP1 group(low CVP1:1.5%;moderate CVP1:0.9%;high CVP1:10.0%;P=0.014).Logistic regression analysis showed that intraoperative hypotension and CVP1>12 mmHg were risk factors for AKI within 72 h after surgery(adjusted odds ratio[aOR]=3.875,95%confidence interval[CI]:1.378–10.900,P=0.010 and aOR=1.147,95%CI:1.006–1.309,P=0.041).Conclusions:CVP that is either too high or too low increases the incidence of postoperative AKI.Sequential fluid therapy based on CVP after patients are transferred to the ICU post-surgery does not reduce the risk of organ dysfunction caused by an excessive amount of intraoperative fluid.However,CVP can be used as a safety limit indicator for perioperative fluid management in high-risk surgical patients.

Hepatic venous pressure gradient measurement guiding nonselective beta-blocker therapy in a patient with clinically significant portal hypertension

Clinically significant portal hypertension(CSPH),defined as a hepatic venous pressure gradient(HVPG)≥10 mmHg,is an independent risk factor for decompensated events in patients with compensated cirrhosis.Currently,the Baveno VII consensus recommends using nonselective beta-blockers to treat compensated cirrhosis in patients with CSPH.Here,we report a unusual case of compensated cirrhosis with CSPH caused by hepatitis B,and we successfully adjust NSBBs drug treatment strategies monitoring by HVPG results and achieve response standards.Timely adjustment of NSBBs drug treatment strategies based on HVPG test results for patients with CSPH can improve the final response rate.

Responsiveness of stroke volume variation and central venous pressure during acute normovolemic and hypervolemic hemodilution

Background Stroke volume variation （SW） is a robust indicator of fluid responsiveness during volume change. We compared the sensibility of SW by Vigileo/Flotrac to central venous pressure （CVP） when volume changes in patients undergoing intraoperative acute normovolemic hemodilution （ANH） and acute hypervolemic hemodilution （AHH）. Methods Forty patients were randomly divided into an ANH group （n=20） and an AHH group （n=20）. All patients received general anesthesia and were mechanically ventilated. Data were collected from 7 different time-points in the ANH group： baseline, after withdrawal of 5%, 10%, and 15% of the estimated blood volume （EBV） and after replacement with an equal volume of 6% hydroxyethyl starch 130/0.4 （HES） in 5% EBV increments to baseline. There were four time points in the AHH group： baseline, after 5%, 10%, and 15% expansion of the EBV with 6% HES. At each time-point, CVP, SW and other hemodynamic parameters measurements were obtained. Results After removal of 10% and 15% EBV, SVV significantly increased from 10.9±3.0 to 14.1±3.4 and 10.9±3.0 to16.0±3.3 （P 〈0.01）, and returned to a final value of 10.6±3.4 after volume replacement. The CVP value was unchanged after removal and replacement of 15% of the EBV. There were no significant changes in SW after 5%, 10% whereas there was a significant reduction after 15% （8.2±1.7） expansion of the EBV compared with baseline （9.9±1.8） （P=0.033）. However, there was a significant increase in CVP after10% （10.3±2.4）, 15% （11.3±2.2） expansion of the EBV compared with baseline （8.2±2.7） （P 〈0.01）. Conclusion SW is a more sensitive parameter for volume than CVP during hypovolemia, on the contrary CVP is more sensitive than SW during hypervolemia.

Assessment effect of central venous pressure in fluid resuscitation in the patients with shock： a multi-center retrospective research

Background Central venous pressure （CVP） and intrathoracic blood volume index （ITBVI） were used to assess the fluid status. It has previously been shown that CVP is not as accurate as ITBVI for all the shock patients. We therefore hypothesized that the change of CVP has the ability to predict fluid responsiveness in some clinical cases of shock. Methods From September 1st 2009 to September 1st 2011, sixty-three patients with shock from different Intensive Care Unit （ICU） were collected into this retrospective study. All the patients received fluid challenge strategy （infusing 300 ml hydroxyethyl starch in 20 minutes）, were monitored with CVP and pulse-indicated continuous cardiac output （PICCO）. The correlation between changes in cardiac index （ACI）, CVP （ACVP） and ITBVI （AITBVI） were analyzed. Fluid responsiveness was defined as an increase in CI 〉10%. Receiver operating characteristic （ROC） curves were generated for ACVP and AITBVI. Results For all the patients, there was no correlation between ACI and ACVP （P=0.073）, but in the subgroup analysis, the correlation between ACI and ACVP was significant in those younger than 60 years old （P=0.018） and those with hypovolemic shock （P=0.001）. The difference of areas under the ROC curves of ACVP and AITBVI were not statistically significant in the group younger than 60 years old or hypovolemic shock group （P 〉0.05, respectively）. However, no similar results can be found in the group older than 60 years old and the other two shock type groups from ROC curves of ACVP and AITBVI. Conclusions ACVP is not suitable for evaluating the volume status of the shock patients with fluid resuscitation regardless of their condition. However, in some ways, ACVP have the ability to predict fluid responsiveness in the younger shock patients or in the hypovolemic shock patients.

Seeing beneath the surface:Harnessing point-of-care ultrasound for internal jugular vein evaluation

Point-of-care ultrasound(POCUS)of the internal jugular vein(IJV)offers a noninvasive means of estimating right atrial pressure(RAP),especially in cases where the inferior vena cava is inaccessible or unreliable due to conditions such as liver disease or abdominal surgery.While many clinicians are familiar with visually assessing jugular venous pressure through the internal jugular vein,this method lacks sensitivity.The utilization of POCUS significantly enhances the visualization of the vein,leading to a more accurate identification.It has been demonstrated that combining IJV POCUS with physical examination enhances the specificity of RAP estimation.This review aims to provide a comprehensive summary of the various sonographic techniques available for estimating RAP from the internal jugular vein,drawing upon existing data.

Correlation of pressure gradient in three hepatic veins with portal pressure gradient

BACKGROUND The liver is one of the most important organs in the human body,with functions such as detoxification,digestion,and blood coagulation.In terms of vascular anatomy,the liver is divided into the left and the right liver by the main portal vein,and there are three hepatic efferent veins(right,middle,and left)and two portal branches.Patients with impaired liver function have increased intrahepatic vascular resistance and splanchnic vasodilation,which may lead to an increase in the portal pressure gradient(PPG)and cause portal hypertension(PHT).In order to measure the increased pressure gradient of portal vein,the hepatic venous pressure gradient(HVPG)can be measured to reflect it in clinical practice.The accuracy of PPG measurements is directly related to patient prognosis.AIM To analyze the correlation between HVPG of three hepatic veins and PPG in patients with PHT.METHODS From January 2017 to December 2019,102 patients with PHT who met the inclusion criteria were evaluated during the transjugular intrahepatic portosystemic shunt procedure and analyzed.RESULTS The mean HVPG of the middle hepatic vein was 17.47±10.25 mmHg,and the mean HVPG of the right and left hepatic veins was 16.34±7.60 and 16.52±8.15 mmHg,respectively.The average PPG was 26.03±9.24 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.15 and 0.02(P=0.164);0.25 and 0.05(P=0.013);and 0.14 and 0.02(P=0.013),respectively.The mean wedged hepatic vein/venous pressure(WHVP)of the middle and left hepatic veins was similar at 29.71±12.48 and 29.1±10.91 mmHg,respectively,and the mean WHVP of the right hepatic vein was slightly lower at 28.01±8.95 mmHg.The mean portal vein pressure was 34.11±8.56 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.26 and 0.07(P=0.009);0.38 and 0.15(P<0.001);and 0.26 and 0.07(P=0.008),respectively.The average free hepatic venous pressure(FHVP)of the right hepatic vein was lowest at 11.67±5.34 mmHg,and the average FHVP of the middle and left hepatic veins was slightly higher at 12.19±4.88 and 11.67±5.34 mmHg,respectively.The average inferior vena cava pressure was 8.27±4.04 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.30 and 0.09(P=0.002);0.18 and 0.03(P=0.078);and 0.16 and 0.03(P=0.111),respectively.CONCLUSION Measurement of the middle hepatic vein HVPG could better represent PPG.Considering the high success rate of clinical measurement of the right hepatic vein,it can be the second choice.

Portal hypertension in patients with nonalcoholic fatty liver disease:Current knowledge and challenges

Portal hypertension(PH)has traditionally been observed as a consequence of significant fibrosis and cirrhosis in advanced non-alcoholic fatty liver disease(NAFLD).However,recent studies have provided evidence that PH may develop in earlier stages of NAFLD,suggesting that there are additional pathogenetic mechanisms at work in addition to liver fibrosis.The early development of PH in NAFLD is associated with hepatocellular lipid accumulation and ballooning,leading to the compression of liver sinusoids.External compression and intraluminal obstacles cause mechanical forces such as strain,shear stress and elevated hydrostatic pressure that in turn activate mechanotransduction pathways,resulting in endothelial dysfunction and the development of fibrosis.The spatial distribution of histological and functional changes in the periportal and perisinusoidal areas of the liver lobule are considered responsible for the pre-sinusoidal component of PH in patients with NAFLD.Thus,current diagnostic methods such as hepatic venous pressure gradient(HVPG)measurement tend to underestimate portal pressure(PP)in NAFLD patients,who might decompensate below the HVPG threshold of 10 mmHg,which is traditionally considered the most relevant indicator of clinically significant portal hypertension(CSPH).This creates further challenges in finding a reliable diagnostic method to stratify the prognostic risk in this population of patients.In theory,the measurement of the portal pressure gradient guided by endoscopic ultrasound might overcome the limitations of HVPG measurement by avoiding the influence of the pre-sinusoidal component,but more investigations are needed to test its clinical utility for this indication.Liver and spleen stiffness measurement in combination with platelet count is currently the best-validated non-invasive approach for diagnosing CSPH and varices needing treatment.Lifestyle change remains the cornerstone of the treatment of PH in NAFLD,together with correcting the components of metabolic syndrome,using nonselective beta blockers,whereas emerging candidate drugs require more robust confirmation from clinical trials.

Portal vein pulsatility:An important sonographic tool assessment of systemic congestion for critical ill patients

In this editorial we comment on the article by Kuwahara et al,published in the recent issue of the World Journal of Cardiology.In this interesting paper,the authors showed a correlation between portal vein pulsatility ratio,examined by bedside ultrasonography,and prognosis of hospitalized patients with acute heart failure.Systemic congestion is being notoriously underdetected in the acutely ill population with conventional methods like clinical examination,biomarkers,central venous pressure estimation and X-rays.However,congestion should be a key therapeutic target due to its deleterious effects to end organ function and subsequently patient prognosis.Doppler flow assessment of the abdominal veins is gaining popularity worldwide,as a valuable tool in estimating comprehensively congestion and giving a further insight into hemodynamics and patient management.

Future directions of noninvasive prediction of esophageal variceal bleeding:No worry about the present computed tomography inefficiency

In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepatic venous pressure gradient(HVPG)and endoscopy with noninvasive methods for predicting esophageal variceal bleeding.The risk factors for bleeding were the size of the varices,the red sign and the Child-Pugh score.The intrinsic core factor that drove these changes was the HVPG.Therefore,the present studies investigating noninvasive methods,including computed tomography,magnetic resonance imaging,elastography,and laboratory tests,are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes,such as bleeding.A single parameter is usually not enough to construct an efficient model.Therefore,multiple factors were used in most of the studies to construct predictive models.Encouraging results have been obtained,in which bleeding prediction was partly reached.However,these methods are not satisfactory enough to replace invasive methods,due to the many drawbacks of different studies.There is still plenty of room for future improvement.Prediction of the precise timing of bleeding using various models,and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.