Effect of hepatic venous pressure gradient in different hepatic venous branches on assessing portal hypertension in cirrhotic patients

BACKGROUND Data regarding the hepatic venous pressure gradient (HVPG) in different hepatic venous branches remain insufficient. AIM To assess portal hypertension using HVPG measurements from the right HVPG (R-HVPG), middle HVPG (M-HVPG), and left HVPG (L-HVPG) hepatic veins, we conducted two sub-studies: Sub-study 1 evaluated the diagnostic value of R-HVPG, M-HVPG and L-HVPG, while sub-study 2 explored the correlation between M-HVPG and portal pressure gradient (PPG) to validate the results of sub-study 1. METHODS We prospectively enrolled 88 patients who underwent HVPG measurements in different hepatic venous branches in sub-study 1. Sub-group 2 covered 16 cirrhotic patients for M-HVPG and PPG comparisons (NCT06358092). Agreement was analyzed using intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS In sub-study 1, M-HVPG demonstrated a significantly higher technical success rate (96.6%) than standard R-HVPG (83.0%) and L-HVPG (93.2%) (P < 0.05). After excluding 15 patients with collateral shunts in the R-HVPG, 73 were included in the final analysis. The mean R-HVPG, M-HVPG and L-HVPG were 16.43 (5.34), 16.98 (5.69) and 15.29 (5.22) mmHg, respectively, with no statistically significant difference (P > 0.05). Agreement between the R-HVPG and M-HVPG was substantial [ICC: 0.70 (0.56-0.80)], superior to the moderate R-HVPG/L-HVPG agreement [ICC: 0.56 (0.37-0.70)]. In sub-study 2, the M-HVPG and PPG showed substantial agreement [ICC: 0.80 (0.52-0.92)]. CONCLUSION Our study demonstrates that M-HVPG achieves the highest technical success rate and superior agreement with R-HVPG, which supports the priority of technical feasibility of HVPG proposed in Baveno VII consensus. Furthermore, the strong correlation with PPG suggests that the M-HVPG potentially reflects accurate portal pressure. Consequently, M-HVPG may be considered a preferred alternative when R-HVPG is unfeasible or unreliable.