Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound
A 57-year-old Hispanic male presented with a 1-day history of altered mental status. He had a past medical history significant for alcohol abuse, hepatitis C and Child-Pugh Class B cirrhosis. He had undergone TIPS placement an unknown number of years before presentation to the ED. Additionally, he had been previously hospitalized for hepatic encephalopathy due to noncompliance with his medical regimen.\nOn physical examination, the patient appeared comfortable and calm. He was alert, but oriented to name only. Vitals signs were temperature 98.1°F pulse 78 beats/ min, respiratory rate 16 breaths/min and blood pressure 130/89 mmHg. The patient was noted to have scleral icterus, and his abdominal exam revealed moderate ascites without tenderness, rebound, or guarding. Unexpectedly, on cardiac auscultation, the patient was noted to have a 2/6 systolic and a 2/6 diastolic murmur with ectopy. A 12-lead electrocardiogram (ECG) was obtained in addition to standard laboratory studies to elucidate the cause of the patient’s altered mental status.\nThe serum white blood cell count was 6,500/mm3 without neutrophilic predominance, hemoglobin of 10 g/dL, BUN of 10 mg/dL and a creatinine of 0.6 mg/dL. The patient was noted to have an elevated ammonia level at138 umol/L. The 12-lead ECG showed normal sinus rhythm with multiple premature atrial contractions. To further assess cardiac function, a bedside EUS was performed. This exam showed an apparent foreign body in the right atrium (). The object could be traced back to the liver and was consistent with a TIPS that had migrated distally into the heart. On closer evaluation using color doppler ultrasound, the patient was noted to have an atrial septal defect. The stent appeared to be located close to this defect, although it had not yet crossed the midline ().\nThe patient was admitted to the hospital for management of his hepatic encephalopathy, as well as for evaluation of the aberrantly located TIPS. During his hospitalization, the patient underwent a formal right upper quadrant ultrasound, which revealed a patent TIPS without definite portal venous clot. The patient did not have further episodes on ectopy as an inpatient. After review with interventional radiology, his case was deemed amenable to outpatient TIPS evaluation with a catheter snare and replacement procedure.