Pulsations of the liver in heart disease

Brain death organ donor supported by a left ventricular assist device showing unexpected congestive liver fibrosis: A case report

INSTRUCTION

Organ transplantation from a brain death donor on mechanical circulatory support is rare. We report a case in which a brain death donor, supported by a left ventricular assist device (LVAD), unexpectedly displayed significant congestive fibrosis of the liver.

PRESENTATION OF CASE

The potential organ donor was diagnosed 23 years previously as having dilated-phase of hypertrophic cardiomyopathy. He had undergone implantation of an LVAD as a bridge to heart transplantation. Laboratory tests and imaging studies performed during the follow-up for his cardiac disease and donor evaluation confirmed that he was suitable for donation of liver. During organ procurement, special attention was paid to preserving LVAD and its device's drive lines and the exposure of the surgical fields was restricted by those devices. Thoracotomy and laparotomy were performed, and the aorta and inferior vena cava were encircled successfully. The gross appearance of liver, however, suggested significant fibrosis. Therefore, the decision was made not to use this liver. Subsequent trichrome-stained permanent sections revealed advanced fibrosis (stage F3-4).

DISCUSSION

As previously reported, organ procurement from donors with LVAD was thought to be demanding procedure because of the limited exposure of surgical field. In addition, it would be difficult to predict severe liver fibrosis in patients with an LVAD without a pathological examination.

CONCLUSION

Donors with mechanical circulatory support systems can be candidate to expand the donor pool, but technical difficulty should be expected owing limited exposure during the donor operation. For liver transplantation, subclinical advanced liver fibrosis should be noted.

"A-wave" liver

The finding and timing of hepatic pulsations can provide important information regarding the status of right heart structures and function. We report a 54-year-old woman with idiopathic dilated cardiomyopathy, who had prominent hepatic presystolic pulsations ("A-wave" liver). The clinical findings and the venous and hepatic pulse recordings are presented and discussed in terms of clinical pathophysiology and significance.

Inferior vena cava echocardiography

The inferior vena cava can be imaged during echocardiography from the subcostal transducer position as an echo-free space at a depth ranging from 6 to 15 cm from the abdominal wall. The normal inferior vena cava M-mode echocardiogram has a "a" and "v" pulsation pattern similar to that seen in the jugular venous tracing and exhibits prominent cyclic respiratory changes. Since right atrial activity can be seen as a pulsation on the M-mode inferior vena cava tracing, specific patterns can be observed during cardiac arrhythmias. In right heart failure the inferior vena cava is usually distended, with diminished respiratory collapse. In tricuspid regurgitation, contrast injected into an arm appears in the inferior vena cava during the "v" wave. "A-wave synchronous" inferior vena cava contrast or a contrast appearance unrelated to the cardiac cycle, frequently with deep inspiration, does not suggest tricuspid regurgitation.