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Chanan EL, Wagener G, Whitlock EL, Berger JC, McAdams-DeMarco MA, Yeh JS, Nunnally ME. Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review. Transplantation 2024:00007890-990000000-00716. [PMID: 38557579 DOI: 10.1097/tp.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.
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Affiliation(s)
- Emily L Chanan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth L Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA
| | - Jonathan C Berger
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Joseph S Yeh
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
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2
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Qiu Y, Hilmi I. The applications of ECMO in liver transplant recipients. Transplant Rev (Orlando) 2024; 38:100816. [PMID: 38104398 DOI: 10.1016/j.trre.2023.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/23/2023] [Accepted: 12/03/2023] [Indexed: 12/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has emerged as a vital instrument for sustaining respiratory and cardiac functions when traditional methods have failed. Its function in managing acute pulmonary and cardiac challenges during liver transplantation (LT) has expanded significantly. While ECMO was initially viewed as a rescue strategy for acute intraoperative or posttransplant complications, its application now also encompasses the pretransplant stage of LT. Our review aims to thoroughly summarize both research and specific cases where ECMO has been utilized across pre- and perioperative phases in liver transplant recipients. By assessing the published literature, we discuss specific indications, the types of ECMO employed, their outcomes, and the unique challenges of applying ECMO during LT. In particular, the pretransplant use of ECMO is increasing, and its prudent introduction prior to LT, supported by meticulous planning, has the potential to optimize patient outcomes. It is challenging to manage liver transplant patients on ECMO. More research and experience are needed to refine the techniques and improve patient outcomes. Furthermore, decision-making must be tailored to each patient's unique circumstances, and a clear, practical, and well-defined plan for subsequent steps is essential.
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Affiliation(s)
- Yue Qiu
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Department of Anesthesiology and Perioperative Medicine Education Office, Liliane S. Kaufmann Building, 3471 Fifth AVE, Suite 402, Pittsburgh, PA 15213, USA.
| | - Ibtesam Hilmi
- Anesthesiology and Perioperative Medicine, Clinical and Translational Science Institute, University of Pittsburgh, School of Medicine, Montefiore Anesthesiology Office 200 Lothrop St, Pittsburgh, PA 15213, USA.
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3
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Qiu Y, Hilmi I. The applications of ECMO in liver transplant recipients. Transplant Rev (Orlando) 2024; 38:100816. [DOI: https:/doi.org/10.1016/j.trre.2023.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
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4
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Ben-Jacob TK, Pasch S, Patel AD, Mueller D. Intraoperative cardiac arrest management. Int Anesthesiol Clin 2023; 61:1-8. [PMID: 37589144 DOI: 10.1097/aia.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Talia K Ben-Jacob
- Department of Anesthesiology, Division of Critical Care Cooper University Hospital, Camden, NJ
| | - Stuart Pasch
- Department of Anesthesiology Cooper University Hospital, Camden, NJ
| | - Akhil D Patel
- Department of Anesthesiology, Division of Critical Care, The George Washington University Hospital, Washington, DC
| | - Dorothee Mueller
- Department of Anesthesiology, Division of Critical Care Vanderbilt University Medical Center Nashville, TN
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5
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Choi MC, Min EK, Yim SH, Lee JG, Koo BN, Kim H, Lee HW, Joo DJ, Kim MS. Successful recovery after veno-arterio-venous extracorporeal membrane oxygenation immediately before liver transplantation in multi-organ failure including acute respiratory distress syndrome: A Case Report. Transplant Proc 2023; 55:684-686. [PMID: 36914436 PMCID: PMC9951045 DOI: 10.1016/j.transproceed.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/18/2023] [Indexed: 03/14/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has emerged as an alternative treatment to conventional ventilation maneuvers in the nontransplantation literature to support acute respiratory distress syndrome. However, the role of ECMO in transplant is unclear, and few case reports have described using ECMO pretransplant. We discuss the successful use of veno-arteriovenous ECMO as a bridge therapy to deceased donor liver transplant (LT) in acute respiratory distress syndrome. Because the incidence of severe pulmonary complications resulting in acute respiratory distress syndrome with multiorgan failure is rare before LT, determining the usefulness of ECMO is challenging. However, in acute but reversible respiratory failure and cardiovascular failure, veno-arteriovenous ECMO provides a useful therapeutic option as a bridge for patients awaiting LT and should be considered if available even in multiorgan failure.
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Affiliation(s)
- Mun Chae Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun-Ki Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hyuk Yim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyohyun Kim
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
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6
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Laici C, Bianchini A, Miglionico N, Bambagiotti N, Vitale G, Fallani G, Ravaioli M, Siniscalchi A. Planned Extracorporeal Life Support Employment during Liver Transplantation: The Potential of ECMO and CRRT as Preventive Therapies-Case Reports and Literature Review. J Clin Med 2023; 12:jcm12031239. [PMID: 36769889 PMCID: PMC9953574 DOI: 10.3390/jcm12031239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
Liver Transplantation (LT) has become the gold standard treatment for End-Stage Liver Disease (ESLD). One of the main strategies to manage life-threatening complications, such as cardio-respiratory failure, is Extracorporeal Membrane Oxygenation (ECMO) in the peri-transplantation period, with different configurations of the technique and in combination with other extracorporeal care devices such as Continuous Renal Replacement Therapy (CRRT). This retrospective study includes three clinical cases of planned ECMO support strategies in LT and evaluates their application compared with current literature exploring PubMed/Medline. The three LT supported with ECMO and CRRT were performed at IRCCS Polyclinic S. Orsola-Malpighi, Bologna. All three cases of patients with compromised organ function analysed produced positive outcomes. The planned use of ECMO and CRRT support in peri-transplantation has allowed the patients to overcome contraindications and successfully undergo LT. In recent years, only a few reports have documented successful LT outcomes performed with intraoperative ECMO in critically ESLD patients. However, the management of LT with ECMO and/or CRRT assistance is an emerging challenge, with the need for more published evidence on this topic to guide treatment choices in patients with severe, acute and reversible respiratory and cardiovascular failure after LT.
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Affiliation(s)
- Cristiana Laici
- Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Amedeo Bianchini
- Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Noemi Miglionico
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
| | - Niccolò Bambagiotti
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
| | - Giovanni Vitale
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence:
| | - Guido Fallani
- Hepatobiliary and Transplant Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
- Hepatobiliary and Transplant Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Antonio Siniscalchi
- Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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7
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Yoon YI, Lim JH, Lee SG, Kang PJ, Hwang GS, Ha SM, Do HY, Hong SK, Huh JW. Role of extracorporeal membrane oxygenation as a salvage therapy for liver transplantation recipients in a high-volume transplant center. Liver Transpl 2023; 29:67-79. [PMID: 36030502 DOI: 10.1002/lt.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/08/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used sporadically in adult orthotopic liver transplantation (OLT) recipients for the treatment of acute cardiopulmonary failure. This retrospective study aimed to identify OLT patients who would benefit from ECMO support. We reviewed 109 OLT patients who received ECMO support for more than 24 h from January 2007 to December 2020. Among the enrolled patients, 15 (13.8%) experienced 18 ECMO-related complications and 12 (11.0%) experienced ECMO reapplication after weaning during the same hospitalization period. The successful weaning rates were 50.98% in patients who received ECMO support during the peritransplantation period (0-30 days from transplantation) and 51.72% in patients who received ECMO support in the post-OLT period (more than 30 days after OLT); 24 (47.1%) and 23 (39.7%) patients survived until hospital discharge, respectively. The 109 enrolled OLT recipients who received ECMO support during the perioperative period had a 1-year survival rate of 42.6%. Multivariate analyses identified the following as significant and independent risk factors for in-hospital mortality: ECMO treatment prior to 2011 ( p = 0.04), septic shock as the indication for ECMO treatment ( p = 0.001), and a total bilirubin level of ≥5.0 mg/dl ( p = 0.02). The outcomes of adult OLT recipients with ECMO treatment were acceptable in terms of weaning success and survival until hospital discharge. This study confirmed that ECMO treatment for OLT recipients with septic shock and elevated bilirubin levels might be associated with a higher in-hospital mortality and demonstrated the importance of a multidisciplinary ECMO team approach.
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Affiliation(s)
- Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jung-Hyeon Lim
- Department of Thoracic and Cardiovascular Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Su-Min Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Ha-Yeon Do
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
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8
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Park J, Lin MY, Wray CL, Kaldas FM, Benharash P, Gudzenko V. Applications and Outcomes of Extracorporeal Life Support Use in Adult Liver Transplantation: A Case Series and Review of Literature. ASAIO J 2022; 68:683-690. [PMID: 34506329 DOI: 10.1097/mat.0000000000001562] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The use of extracorporeal life support (ECLS) is increasingly reported in adult liver transplantation (LT). However, neither the role of ECLS in the perioperative setting for LT nor its outcomes has been well defined. We performed a retrospective chart review of all adult LT patients at our institution who received ECLS from 2004 to 2021. We also conducted a comprehensive literature search for adult LT cases that involved perioperative ECLS for respiratory or cardiac failure. Over the study period, 11 LT patients required ECLS at our institution, two for respiratory and nine for cardiac failure. Both patients with respiratory failure received ECLS as a bridge to LT and survived to discharge. Nine patients required ECLS for acute cardiac failure either intraoperatively or postoperatively, and two survived to discharge. In the literature, we identified 35 cases of respiratory failure in LT patients requiring perioperative ECLS. Applications included preoperative bridge to LT (n = 6) and postoperative rescue (n = 29), for which overall survival was 44%. We identified 31 cases of cardiac failure in LT patients requiring either ECLS or cardiopulmonary bypass for cardiac support or rescue for intraoperative or postoperative cardiac failure (n = 30). There is evidence for consideration of ECLS as a bridge to LT in patients with potentially reversible respiratory failure or as rescue therapy for respiratory failure in posttransplant patients. ECLS has a prohibitively high risk of futility in pretransplant patients with cardiac failure but may have a role in LT patients with a functioning graft and potentially reversible cardiac failure.
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Affiliation(s)
- Jeieung Park
- From the Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Y Lin
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, California, Los Angeles
| | - Christopher L Wray
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, California, Los Angeles
| | - Fady M Kaldas
- Dumont-UCLA Transplant and Liver Cancer Center, Department of Surgery, David Geffen School of Medicine, University of California, California, Los Angeles
| | - Peyman Benharash
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, California, Los Angeles
| | - Vadim Gudzenko
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, California, Los Angeles
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9
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Reid TD, Kratzke IM, Dayal D, Raff L, Serrano P, Kumar A, Zendel A, Herdman V, Gallaher J, Carlson R, Charles AG, Desai CS. The role of extracorporeal membrane oxygenation in adult liver transplant patients: A qualitative systematic review of literature. Artif Organs 2021; 46:578-596. [PMID: 34816462 DOI: 10.1111/aor.14120] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A paucity of evidence exists regarding risks and benefits of extracorporeal membrane oxygenation (ECMO) in adult liver transplantation. METHODS This was a systematic review conducted from January 1, 2000 to April 24, 2020 of adult liver transplant recipients (pre- or post-transplant) and donors who underwent Veno-arterial or Veno-venous ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS Forty-one articles were identified that fit criteria. A total of 183 donors were placed on ECMO, with recipient complication profiles and mortality that mirrored rates from standard criteria donors. Sixty-one recipients were placed on ECMO intraoperatively or postoperatively. Most patients experienced at least one complication with infections as the most common cause and minimal complications specifically related to ECMO use. Multisystem organ failure (MSOF) and infections were more common among liver recipients who died compared to those who survived. Overall mortality at 90 days was 45.9%. Causes of death were most commonly MSOF and infections. CONCLUSIONS ECMO use in adult liver transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO parallel that of recipients from standard criteria donors, and morbidity and mortality of recipients placed on ECMO are similar to other ECMO populations.
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Affiliation(s)
- Trista D Reid
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ian M Kratzke
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diana Dayal
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Raff
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Pablo Serrano
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aman Kumar
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alex Zendel
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Victoria Herdman
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jared Gallaher
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rebecca Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony G Charles
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chirag S Desai
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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10
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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11
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Van Hoof L, Rega F, Devroe S, Degezelle K, Pirenne J, Neyrinck A. Successful resuscitation after hyperkalemic cardiac arrest during liver transplantation by converting veno-venous bypass to veno-arterial ECMO. Perfusion 2020; 36:766-768. [PMID: 33043795 DOI: 10.1177/0267659120963898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Intraoperative cardiac arrest (ICA) is a feared complication during liver transplantation (LTx), typically occurring during reperfusion. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used for post-reperfusion cardiac arrest. CASE REPORT We present a case of successful resuscitation after hyperkalemic ICA during the pre-anhepatic phase of a second liver transplantation by converting veno-venous bypass (VVB) to VA-ECMO. DISCUSSION While this technique has been recommended for ICA during reperfusion, it has never been reported during the pre-anhepatic phase. VA-ECMO can be a lifesaving extension to cardiopulmonary resuscitation for ICA during LTx with beneficial neurological outcome by providing perfusion while the cause of ICA is reversed. CONCLUSION Conversion of VVB to VA-ECMO should be considered in all patients who suffer from ICA during LTx with use of VVB. With VVB installed, conversion to VA-ECMO is fast and effective. If VVB is not used, early VA-ECMO should be considered for ICA.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sarah Devroe
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Karlien Degezelle
- Department of Perfusion, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
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12
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Romano DN, Smith NK, Itagaki S, Bekki Y, Gunasekaran G, Zerillo J. A Case Report of Venoarterial ECMO as Salvage Therapy for Prolonged Cardiac Arrest Following Post-Reperfusion Intracardiac Thrombosis During Orthotopic Liver Transplantation. Semin Cardiothorac Vasc Anesth 2020; 25:62-66. [PMID: 32838666 DOI: 10.1177/1089253220952628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this report we describe the use of intraoperative venoarterial ECMO as salvage therapy in a unique case of post-reperfusion intracardiac thrombosis during liver transplantation with prolonged ACLS and coagulopathy. The limited literature on intraoperative ECMO as salvage therapy in liver transplantation is reviewed.
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Affiliation(s)
- Diana N Romano
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Yuki Bekki
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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The Utility of ECMO After Liver Transplantation: Experience at a High-volume Transplant Center and Review of the Literature. Transplantation 2019; 103:1568-1573. [DOI: 10.1097/tp.0000000000002716] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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14
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Goussous N, Akbar H, LaMattina JC, Hanish SI, Barth RN, Bruno DA. Extracorporeal membrane oxygenation support following liver transplantation—A case series. Clin Transplant 2019; 33:e13628. [DOI: 10.1111/ctr.13628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Naeem Goussous
- University of Maryland School of Medicine Baltimore Maryland
| | - Hashem Akbar
- University of Maryland School of Medicine Baltimore Maryland
| | | | | | - Rolf N. Barth
- University of Maryland School of Medicine Baltimore Maryland
| | - David A. Bruno
- University of Maryland School of Medicine Baltimore Maryland
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15
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Kim I, Nissen N, Steggerda J, Gereboff A, Sharma V, Kariger R, Klein A, Annamalai A, Todo T, Nurok M, Dong E, Friedman O, Jordan S, Ramzy D. Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Failure in a Liver Transplant Patient: A Case Report. Transplant Proc 2018; 50:4038-4041. [DOI: 10.1016/j.transproceed.2018.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/04/2018] [Indexed: 01/28/2023]
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16
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Zhang L, Tian M, Wei L, Zhu Z. Expanded Criteria Donor-Related Hyperkalemia and Postreperfusion Cardiac Arrest During Liver Transplantation: A Case Report and Literature Review. Ann Transplant 2018; 23:450-456. [PMID: 29967315 PMCID: PMC6248011 DOI: 10.12659/aot.909308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Liver transplantation (LT) using extended criteria donor (ECD) grafts is frequently associated with a high flush fluid potassium concentration (FFK) and acute hyperkalemia after reperfusion, which puts patients at greater risk of postreperfusion cardiac arrest (PRCA). Case Report Herein, we present a case with an extremely high FFK that was successfully pretreated to avoid the risk of PRCA. A 3-year-old boy with biliary atresia underwent LT from a 623-g donation after brain death liver graft with localized frostbite on the right lobe surface. The FFK was 18.8 mmol/L after flushing with 1000 mL of 5% albumin. To prevent PRCA due to acute hyperkalemia, further portal vein (PV) flush, retrograde reperfusion via the inferior vena cava, and antegrade reperfusion via the PV were adopted to remove the excessive potassium ions. Ultimately, the liver graft was reperfused when the perfused blood potassium concentration was 7.5 mmol/L without subsequent development of PRCA during the immediate reperfusion period. Nevertheless, the patient still experienced vasoplegic syndrome during the late reperfusion period. Conclusions Our case illustrates that the FFK measurement is helpful for identifying ECD-related hyperkalemia and for providing advance warning of PRCA. Future investigations are warranted to confirm the relationship between high FFK and PRCA and to observe the effectiveness of other interventions to prevent PRCA due to ECD-related hyperkalemia.
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Affiliation(s)
- Liang Zhang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ming Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Lin Wei
- Division of Liver Transplantation Surgery, Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland).,Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Zhijun Zhu
- Division of Liver Transplantation Surgery, Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland).,Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
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17
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Herborn J, Lewis C, De Wolf A. Liver Transplantation: Perioperative Care and Update on Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Lee KW, Cho CW, Lee N, Choi GS, Cho YH, Kim JM, Kwon CHD, Joh JW. Extracorporeal membrane oxygenation support for refractory septic shock in liver transplantation recipients. Ann Surg Treat Res 2017; 93:152-158. [PMID: 28932731 PMCID: PMC5597539 DOI: 10.4174/astr.2017.93.3.152] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/21/2017] [Accepted: 04/18/2017] [Indexed: 12/13/2022] Open
Abstract
Purpose This study was designed to assess the outcome of the extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients with refractory septic shock and predict the prognosis of those cases. Methods From February 2005 to October 2012, ECMO was used in 8 cases of refractory septic shock. Laboratory values including lactate and total bilirubin level just before starting ECMO were obtained and sepsis-related organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACH) II score and simplified acute physiology score (SAPS) 3 were calculated. Subsequent peak serum lactate and total bilirubin level, and SOFA score after 24 hours of starting ECMO were measured. Results Comparisons were made between survivors and nonsurvivors. ECMO was weaned off successfully in 3 patients (37.5%) and 2 patients (25%) survived to hospital discharge. Clinical scores including SOFA, APACH II, and SAPS3 and laboratory results including lactate, total bilirubin and CRP were not significantly different between survivor and nonsurvivor groups. Lactate level and SOFA score tended to decrease after ECMO support in survivor group and total bilirubin and CRP level tended to increase in nonsurvivor group. Conclusion Our findings suggest that the implantation of ECMO might be considered in highly selected LT recipients with refractory septic shock.
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Affiliation(s)
- Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Woo Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nuri Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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19
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Palanisamy AP, Nadig SN, Chedister GR, Dowden JE, Koch DG, Stoll WD, McGillicuddy JW, Chavin KD. Use of intra-aortic counterpulsation in cardiogenic shock post-liver transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Arun P Palanisamy
- Department of Surgery; Case Western Reserve University; Cleveland OH USA
- Division of Hepatobiliary and Transplant Surgery; University Hospitals Cleveland Medical Center; Cleveland OH USA
| | - Satish N Nadig
- Division of Transplant Surgery Medical University of South Carolina; Charleston SC USA
| | - Gabriel R Chedister
- Division of Transplant Surgery Medical University of South Carolina; Charleston SC USA
| | - Jacob E Dowden
- Department of Surgery; College of Medicine; University of Tennessee; Chattanooga TN USA
| | - David G Koch
- Department of Gastroenterology & Hepatology; Medical University of South Carolina; Charleston SC USA
| | - William D Stoll
- Department of Anesthesia and Perioperative Medicine; Medical University of South Carolina; Charleston SC USA
| | - John W McGillicuddy
- Division of Transplant Surgery Medical University of South Carolina; Charleston SC USA
| | - Kenneth D Chavin
- Department of Surgery; Case Western Reserve University; Cleveland OH USA
- Division of Hepatobiliary and Transplant Surgery; University Hospitals Cleveland Medical Center; Cleveland OH USA
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20
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Nandhabalan P, Loveridge R, Patel S, Willars C, Best T, Vercueil A, Vilca-Melendez H, Deep A, Heaton N, Auzinger G. Extracorporeal membrane oxygenation and pediatric liver transplantation, "a step too far?": Results of a single-center experience. Liver Transpl 2016; 22:1727-1733. [PMID: 27600579 DOI: 10.1002/lt.24626] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/16/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Prashanth Nandhabalan
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom
| | - Robert Loveridge
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom
| | - Sameer Patel
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom
| | - Christopher Willars
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom.,Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Thomas Best
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom
| | - Andre Vercueil
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom
| | | | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Georg Auzinger
- Department of Critical Care/ECMO Service, King's College Hospital, London, United Kingdom.,Institute of Liver Studies, King's College Hospital, London, United Kingdom
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21
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Kim S, DeMaria S, Cohen E, Silvay G, Zerillo J. Prolonged Intraoperative Cardiac Resuscitation Complicated by Intracardiac Thrombus in a Patient Undergoing Orthotopic Liver Transplantation. Semin Cardiothorac Vasc Anesth 2016; 20:246-51. [DOI: 10.1177/1089253216652223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We report the case of successful resuscitation after prolonged cardiac arrest during orthotopic liver transplantation. After reperfusion, the patient developed ventricular tachycardia, complicated by intracardiac clot formation and massive hemorrhage. Transesophageal echocardiography demonstrated stunned and nonfunctioning right and left ventricles, with developing intracardiac clots. Treatment with heparin, massive transfusion and prolonged cardiopulmonary resuscitation ensued for 51 minutes. Serial arterial blood gases demonstrated adequate oxygenation and ventilation during cardiopulmonary resuscitation. Cardiothoracic surgery was consulted for potential use of extracorporeal membrane oxygenation, however, the myocardial function improved and the surgery was completed without further intervention. On postoperative day 6, the patient was extubated without neurologic or cardiac impairment. The patient continues to do well 2 years posttransplant, able to perform independent daily activities of living and his previous job. This case underscores the potential for positive outcomes with profoundly prolonged, effective advanced cardiovascular life support in patients who experience postreperfusion syndrome.
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Affiliation(s)
- Sang Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edmond Cohen
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Silvay
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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