Effect of Right Ventricular Dysfunction on Dynamic Preload Indices to Predict a Decrease in Cardiac Output After Inferior Vena Cava Clamping During Liver Transplantation

Clinical impact of mild to moderate pulmonary hypertension in living-donor liver transplantation

Severe pulmonary hypertension (PHT) is a contraindication to liver transplantation (LT); however, the prognostic implication of mild to moderate PHT in living-donor LT (LDLT) is unknown. The study cohort retrospectively included 1307 patients with liver cirrhosis who underwent LDLT. PHT was defined as a mean pulmonary artery pressure (PAP) of ≥25 mmHg, measured intraoperatively just before surgery. The primary endpoint was graft failure within 1 year after LDLT, including retransplantation or death from any cause. The secondary endpoints were in-hospital adverse events. In the overall cohort, the median Model for End-stage Liver Disease-Sodium (MELD-Na) score was 19, and 100 patients (7.7%) showed PHT. During 1-year follow-up, graft failure occurred in 94 patients (7.2%). Patients with PHT had lower 1-year graft survival (86% vs. 93.4%, P = 0.005) and survival rates (87% vs. 93.6%, P = 0.011). Mean PAP was associated with a high risk of in-hospital adverse events and 1-year graft failure. Adding the mean PAP to the clinical risk model improved the risk prediction. In conclusion, mild to moderate PHT was associated with higher risks of 1-year graft failure and in-hospital events, including mortality after LDLT in patients with liver cirrhosis. Intraoperative mean PAP can help predict the early clinical outcomes after LDLT.

Effect of Remote Ischemic Preconditioning Conducted in Living Liver Donors on Postoperative Liver Function in Donors and Recipients Following Liver Transplantation: A Randomized Clinical Trial

OBJECTIVE

This study aimed to assess the effects of remote ischemic preconditioning (RIPC) on liver function in donors and recipients after living donor liver transplantation (LDLT).

BACKGROUND

Ischemia reperfusion injury (IRI) is known to be associated with graft dysfunction after liver transplantation. RIPC is used to lessen the harmful effects of IRI.

METHODS

A total of 148 donors were randomly assigned to RIPC (n = 75) and control (n = 73) groups. RIPC involves 3 cycles of 5-minute inflation of a blood pressure cuff to 200 mm Hg to the upper arm, followed by 5-minute reperfusion with cuff deflation. The primary aim was to assess postoperative liver function in donors and recipients and the incidence of early allograft dysfunction and graft failure in recipients.

RESULTS

RIPC was not associated with any differences in postoperative aspartate aminotransferase (AST) and alanine aminotransferase levels after living donor hepatectomy, and it did not decrease the incidence of delayed graft hepatic function (6.7% vs 0.0%, P = 0.074) in donors. AST level on postoperative day 1 [217.0 (158.0, 288.0) vs 259.5 (182.0, 340.0), P = 0.033] and maximal AST level within 7 postoperative days [244.0 (167.0, 334.0) vs 296.0 (206.0, 395.5), P = 0.029) were significantly lower in recipients who received a preconditioned graft. No differences were found in the incidence of early allograft dysfunction (4.1% vs 5.6%, P = 0.955) or graft failure (1.4% vs 5.6%, P = 0.346) among recipients.

CONCLUSIONS

RIPC did not improve liver function in living donor hepatectomy. However, RIPC performed in liver donors may be beneficial for postoperative liver function in recipients after living donor liver transplantation.

Early postoperative weight gain is associated with increased risk of graft failure in living donor liver transplant recipients

Fluid overload (FO) has been shown to adversely affect multiple organs and survival in critically ill patients. Liver transplantation (LT) carries the risk of massive transfusion, which frequently results in FO. We investigated the association of postoperative weight gain with graft failure, early allograft dysfunction (EAD), and overall mortality in LT. 1833 living donor LT (LDLT) recipients were retrospectively analysed. Patients were divided into 2 groups according to postoperative weight gain (<3% group [n = 1391] and ≥3% group [n = 442]) by using maximally selected log-rank statistics for graft failure. Multivariate Cox and logistic regression analyses were performed. The ≥3% group was associated with graft failure (adjusted HR [aHR], 1.763; 95% CI, 1.248–2.490; P = 0.001). When postoperative weight change was used as a continuous variable, the aHR for each 1% increase in postoperative weight was 1.045 (95% CI, 1.009–1.082; P = 0.015). In addition, the ≥3% group was associated with EAD (adjusted OR [aOR], 1.553; 95% CI, 1.024–2.356; P = 0.038) and overall mortality (aHR, 1.731; 95% CI, 1.182–2.535; P = 0.005). In conclusion, postoperative weight gain may be independently associated with increased risk of graft failure, EAD, and mortality in LDLT recipients.

Beat-to-Beat Tracking of Pulse Pressure and Its Respiratory Variation Using Heart Sound Signal in Patients Undergoing Liver Transplantation

Purpose: To investigate the possibility of esophageal phonocardiography as a monitor for invasively measured pulse pressure (PP) and its respiratory variation (PPV) in patients undergoing liver transplantation. Methods: In 24 liver transplantation recipients, all hemodynamic parameters, including PP and PPV, were measured during five predetermined surgical phases. Simultaneously, signals of esophageal heart sounds (S1, S2) were identified, and S1–S2 interval (phonocardiographic systolic time, PST) and its respiratory variation (PSV) within a 20-s window were calculated. Beat-to-beat correlation between PP and its corresponding PST was assessed during each time window, according to the surgical phases. To compare PPV and PSV along with 5 phases (a total of 120 data pairs), Pearson correlation was conducted. Results: Beat-to-beat PST values were closely correlated with their corresponding 3360 pairs of PP values (median r = 0.568 [IQR 0.246–0.803]). Compared with the initial phase of surgery, correlation coefficients were significantly lower during the reperfusion period (median r = 0.717 [IQR 0.532–0.886] vs. median r = 0.346 [IQR 0.037–0.677]; p = 0.002). The correlation between PSV and PPV showed similar variation according to the surgical phases (r = 0.576 to 0.689, p < 0.05, for pre-reperfusion; 0.290 to 0.429 for the post-reperfusion period). Conclusions: Continuous monitoring of intraoperative PST with an esophageal stethoscope has the potential to act as an indirect estimator of beat-to-beat arterial PP. Moreover, PSV appears to exhibit a trend similar to that of PPV with moderate accuracy. However, variation according to the surgical phase limits the merit of the current results, thereby necessitating cautious interpretation.

Low Mean Arterial Blood Pressure is Independently Associated with Postoperative Acute Kidney Injury After Living Donor Liver Transplantation: A Propensity Score Weighing Analysis

Background

As end-stage liver disease progresses, renal blood flow linearly correlates with mean arterial blood pressure (MBP) due to impaired autoregulation. We investigated whether the lower degree of postoperative MBP would predict the occurrence of postoperative acute kidney injury (AKI) after liver transplantation.

Material/Methods

This retrospective study enrolled 1,136 recipients with normal preoperative kidney function. Patients were categorized into two groups according to the averaged postoperative MBP: <90 mmHg (MBP_below90) and ≥90 mmHg (MBP_over90). The primary endpoint was occurrence of postoperative AKI, defined by the creatinine criteria of the Kidney Disease Improving Global Outcomes. The logistic regression model with inverse probability treatment weighting (IPTW) of propensity score was used to compare the risk of postoperative AKI between two groups.

Results

MBP_below90 group (83.0±5.1 mmHg) showed higher prevalence and risk of postoperative AKI (74.2% versus 62.6%, p<0.001; IPTW-OR 1.34 [1.12–1.61], p=0.001) compared with MBP_over90 group (97.3±5.2 mmHg). When stratified by quartiles of baseline cystatin C glomerular filtration ratio (GFR), the association between MBP_below90 and postoperative AKI remained significant only with the lowest quartile (cystatin C GFR ≤85 mL/min/1.73 m²; IPTW-OR 2.24 [1.53–3.28], p<0.001), but not with 2^nd–4^th quartiles.

Conclusions

Our results suggest that maintaining supranormal MBP over 90 mmHg may be beneficial to reduce the risk of post-LT AKI, especially for liver transplant recipients with cystatin C GFR ≤85 mL/min/1.73 m².

Predictors to Intravenous Fluid Responsiveness

Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.

Predictors to Intravenous Fluid Responsiveness

Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.

Pulmonary hypertension attenuates the dynamic preload indicators increase during experimental hypovolemia

Background

Pulse pressure (PPV) and stroke volume (SVV) variations may not be reliable in the setting of pulmonary hypertension and/or right ventricular (RV) failure. We hypothesized that RV afterload increase attenuates SVV and PPV during hypovolemia in a rabbit model of pulmonary embolism (PE) secondary to RV dysfunction.

Methods

Seven anesthetized and mechanically ventilated rabbits were studied during four experimental conditions: normovolemia, blood withdrawal, pulmonary embolism and fluid loading of a colloidal solution. Central venous, RV and left ventricular (LV) pressures, and infra-diaphragmatic aortic blood flow (AoF) and pressure were measured. SV was estimated by the integral of systolic AoF. We analyzed RV and LV function through stroke work output curves. PPV and SVV were obtained by the variation of beat-to-beat PP and SV, respectively. We assessed RV and LV diastolic and systolic function by the time rate of relaxation (tau) and the ratio of the first derivative of ventricular pressure and the highest isovolumic developed pressure (dP/dt/DP), respectively. The vasomotor tone was estimated by the dynamic arterial elastance (Ea_dyn = PPV/SVV).

Results

PPV and SVV increased significantly during hemorrhage and returned to baseline values after PE which was associated to biventricular right-downward of the stroke work curves and a decrease of AoF and SV (P < 0.05). RV systo-diastolic function and LV systolic function were impaired. All the animals were nonresponders after volume expansion. Ea_dyn did not show any significant change during the different experimental conditions.

Conclusions

The dynamic preload indicators (SVV and PPV) were significantly reduced after a normotensive PE in hypovolemic animals, mainly by the systo-diastolic dysfunction of the RV associated with LV systolic impairment, which makes the animals nonresponsive to volume loading. This normalization of dynamic preload indices may prevent the detrimental consequence of fluid loading.

[Influence of pressure- and volume-controlled ventilation on pulse pressure variations: randomized study]

OBJECTIVE

Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation.

STUDY DESIGN

Double-blind randomized study, cross-over design.

PATIENTS

Patients in intensive care unit after a cardiac surgery.

METHOD

Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes.

RESULTS

Among the 26 patients analyzed, mean ΔPP value was de 14.0±7.3% in VVC and 11.8±6.2% in VPC (P<0,0001). On Bland-Altman representation, mean bias was +2.2±2.3% and inferior and superior limits of agreement were respectively -2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified.

CONCLUSION

ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.

Evaluation of the right ventricular ejection fraction during classic orthotopic liver transplantation without venovenous bypass

BACKGROUND

Right ventricular (RV) function is sensitive to changes in cardiac loading conditions, and RV dysfunction may contribute to hemodynamic instability during orthotopic liver transplantation (OLT). Thus, we evaluated RV function and its role in hemodynamic instability during classic OLT without venovenous bypass (VVB).

METHODS

Thirty patients undergoing classic OLT without VVB were studied. Right ventricular ejection fraction (RVEF) was measured using a modified pulmonary artery catheter. Hemodynamic data were recorded at pre-determined time points: T0, baseline; T1-T3: 5, 15, and 30 min after clamping; T4-T7: 5, 15, 30, and 120 min after reperfusion; T8 and T9: 24 and 48 h after surgery.

RESULTS

The baseline RVEF was lower than normal value. RVEF decreased significantly from T1 to T4 and returned to baseline beginning at T5. At 24 and 48 h after surgery, RVEF was higher than baseline value. RVEF was correlated with stroke volume index and post-reperfusion syndrome during OLT. Compared to the low MELDs group, RVEF in the high MELDs group was lower at T1, T2, and T4.

CONCLUSIONS

Right ventricular function was compromised during the anhepatic and early reperfusion stages in patients undergoing classic OLT without VVB, particularly in the high MELD score patients. Close monitoring of RV function in these patients should be considered.

Is stroke volume variation a useful preload index in liver transplant recipients? A retrospective analysis

BACKGROUND

The right ventricular end-diastolic volume index (RVEDVI) is a good indicator of preload in patients undergoing liver transplantation. Although dynamic indices, such as stroke volume variation (SVV), have been used as reliable indicators in predicting fluid responsiveness, the evaluation of the relationship between SVV and direct preload status is limited. We investigated the relationship between SVV and RVEDVI, and tested the cutoff value of SVV to predict RVEDVI during liver transplantation.

METHODS

A total of 150 data pairs in 30 living donor liver transplant recipients were retrospectively investigated. Hemodynamic parameters, including SVV and RVEDVI were obtained from each patient at the 5 specific time points. Linear regression and receiver operating characteristic (ROC) curve analyses were performed.

RESULTS

The SVV significantly correlated with the RVEDVI (r = -0.616, P < 0.001). Cutoff values for the upper and lower tertiles of RVEDVI were 157 mL/m(2) and 128 mL/m(2), respectively. Tertile analysis indicated that upper tertile of RVEDVI had a significantly lower SVV than the middle tertile (median; 5% vs 8%, P < 0.05), and middle tertile of RVEDVI had a significantly lower SVV than the lower tertile (median; 8% vs 11%, P < 0.05). A 6% cutoff value of SVV estimated the upper tertile RVEDVI (>157 mL/m(2)) with the area under the curve of ROC curve of 0.832. A 9% cutoff value of SVV estimated the lower tertile RVEDVI (<128 mL/m(2)) with the area under the curve of ROC curve of 0.792.

CONCLUSION

SVV may be a valuable estimator of RVEDVI in patients undergoing liver transplantation.

Stroke volume variation derived by arterial pulse contour analysis is a good indicator for preload estimation during liver transplantation

BACKGROUND

Accurate determination of preload during liver transplantation is essential. Continuous right ventricular end diastolic volume index (RVEDVI) has been shown to be a better preload indicator during liver transplantation than the filling pressures. However, recent evidence has shown that dynamic variables, in this case stroke volume variation (SVV), are also good indicators of preload responsiveness. In this study, we evaluated the correlation between SVV, which we derived from arterial pulse contour analysis and RVEDVI.

METHODS

In this study, we looked for possible relationships between SVV obtained through FloTrac/Vigileo monitor, central venous pressure (CVP), pulmonary arterial occlusion pressure (PAOP), and RVEDVI in 30 patients undergoing liver transplantation. Measurements were taken at 11 defined points during different phases across liver transplantation. Each set of measurement was taken during a steady state, which means at least 15 minutes elpased after any changes occured in either the infusion rate of catecholamines or ventilator settings. Pearson's test was used for correlation estimation.

RESULTS

There was a statistically significant (P<.01) relationship between SVV and RVEDVI with a correlation coefficient of -0.87. The correlations between CVP (r=0.42), PAOA (r=0.46), and RVEDVI were less strong.

CONCLUSION

We conclude that SVV is a good indicator for preload estimation during liver transplantation. A higher SVV value is associated with a more hypovolemic fluid status.

The impact of portopulmonary hypertension on intraoperative right ventricular function of living donor liver transplant recipients

BACKGROUND

Portopulmonary hypertension (PPH) burdens a right ventricle (RV) already exposed to physiologic stress during liver transplantation. The magnitude of the impact of PPH on RV function, especially early reperfusion, has not been evaluated adequately by prospective controlled trials. In this study, we prospectively quantified the impact of PPH on the RV function in living donor liver transplant recipients.

METHODS

Twenty patients undergoing living donor liver transplant were stratified based on mean pulmonary artery pressure (mPAP) into a control group (mPAP <25 mm Hg) and a PPH group (mPAP ≥25 mm Hg). Standard anesthetic technique and monitoring were used. Fiberoptic pulmonary artery catheters enabled to measure RV ejection fraction (RVEF) were used. Hemodynamics were recorded after induction of anesthesia, the end of hepatectomy, before portal unclamping, 5 and 30 minutes after reperfusion, and at skin closure.

RESULTS

The PPH group had significantly lower RVEF, stroke volume, and higher central venous pressure and RV end-diastolic volume index after portal unclamping versus the controls. Pulmonary vascular resistance index and mPAP were significantly higher throughout the operation in the PPH group, but RV stroke work index did not differ significantly between groups. RVEF was significantly reduced in the PPH group after reperfusion compared with baseline, but the control group did not experience such a reduction.

CONCLUSIONS

Mild to moderate PPH was associated with reduced RVEF during liver transplantation, especially after reperfusion, likely because of a reduced RV contractile reserve in PPH patients. This reduction in RVEF was clinically well tolerated by patients with mild to moderate PPH.

Does stroke volume variation predict intraoperative blood loss in living right donor hepatectomy?

BACKGROUND

Although stroke volume variation (SVV) is a valuable index of preload responsiveness, there is limited information about the association between low SVV and increased hepatectomy-related bleeding. We therefore evaluated whether SVV predicts blood loss during living donor hepatectomy.

METHODS

We evaluated 93 adult liver donors undergoing right hepatectomy for transplantation. Arterial blood pressure, heart rate, body temperature, central venous pressure, SVV, cardiac output, and systemic vascular resistance were measured. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to determine independent factors and optimal cutoff values of hemodynamic parameters for predicting intraoperative blood loss ≥ 700 mL.

RESULTS

Of these 93 donors, 36 (38.7%) had blood loss ≥ 700 mL. Univariate logistic regression analysis showed that factors associated with blood loss ≥ 700 mL included heart rate, SVV, cardiac output, and systemic vascular resistance. Multivariate logistic regression analysis revealed that only SVV was an independent predictor of blood loss ≥ 700 mL. ROC curve analysis showed that the optimal cutoff value for SVV predicting blood loss ≥ 700 mL was 6% (area under the curve = 0.64).

CONCLUSIONS

SVV is a significant independent predictor of blood loss ≥ 700 mL during donor hepatectomy, suggesting that low SVV may provide useful information on intraoperative bleeding in donors undergoing right hepatectomy.

A retrospective case-control study of intraoperative cardiac dysfunction in elderly patients (≥60 years) undergoing live donor liver transplantation

BACKGROUND

The age range of patients accepted for the orthotopic liver transplantation (OLT) has widened. Concerns have arisen, therefore, about the ability of the hearts of elderly patients to manage these stressful conditions. The aim of this study was to investigate the preoperative echocardiographic findings and the intraoperative cardiac dysfunction among elderly cirrhotic recipients undergoing live donor OLT.

METHODS

In this retrospective case-control study we evaluated clinical data, echocardiography, and intraoperative right-sided heart hemodynamic measurements from 2007 and 2009 among 56 recipients aged at least 60 years who were matched for gender and the severity of cirrhosis. Intraoperative cardiac dysfunction was defined as a decreased left ventricular stroke work index despite an increase in right ventricular end diastolic volume index (RVEDVI) or pulmonary artery occlusion pressure (PAOP). We compared measurements at predetermined times during the anhepatic and neohepatic periods with those at baseline.

RESULTS

Older recipients (mean, 63 years; range, 60-69) showed significantly reduced early diastolic annular velocity (E'), early maximal ventricular filling velocity (E)/late filling velocity (A) ratio, and increased A on echocardiography versus younger recipients (mean 48 years; range, 31-56). We observed negative correlation between age and E' (r = -0.44; P < .001) and a positive correlation between age and E/E' (r = 0.31; P < .01). The incidence of intraoperative cardiac dysfunction did not differ between case and control groups with an increase of RVEDVI (11.4% vs 10.6%) or PAOP (27.2% vs 25.0%) during the anhepatic and neohepatic periods. A higher proportion of older recipients needed inotropic agents during OLT (60.7% vs 39.3%; P = .04).

CONCLUSIONS

OLT patients of ar least 60 years of age may not show a greater incidence of cardiac dysfunction during OLT versus younger ones, although older recipients showed reduced diastolic function and more frequently required inotropic support.

Evaluation of intraoperative brain natriuretic peptide as a predictor of 1-year mortality after liver transplantation

BACKGROUND

Although brain natriuretic peptide (BNP), a marker of cardiac dysfunction, has been known to predict postoperative mortality, little is known about the postoperative prognostic ability of BNP in liver transplantation (OLT) recipients. We aimed to determine whether intraoperative BNP level can predict 1-year all-cause mortality after OLT.

METHODS

We retrospectively investigated 525 OLT recipients. BNP and hemodynamic parameters were simultaneously measured 1 hour after induction of anesthesia. Cox regression analysis and receiver operating characteristic curve analysis were performed to determine clinical predictors and optimal cutoff values of post-OLT mortality.

RESULTS

The 1-year all-cause mortality rate was 9.7% (51/525). Median BNP concentration was significantly higher in nonsurvivors than in survivors (114 vs 56 pg/mL, P < .001). Significant factors in univariate Cox regression analysis were Child-Pugh score, model for end-stage liver disease (MELD) score, logBNP, hemoglobin, creatinine, heart rate, systolic pulmonary arterial pressure, and central venous pressure. In multivariate Cox regression analysis, independent predictors of posttransplant mortality were MELD score and logBNP. However, simultaneously measured hemodynamic parameters did not remain predictors. BNP levels greater than a cutoff of 136 pg/mL (specificity = 83.5%, negative predictive value = 93.6%) were associated with increased post-OLT mortality (log-rank test P < .001).

CONCLUSIONS

Intraoperative BNP level is an independent predictor of 1-year all-cause mortality after OLT with a high negative predictive value, suggesting that its measurement appears useful in identifying patients at low risk of post-OLT mortality.

Alterations in QT interval in patients undergoing living donor liver transplantation

BACKGROUND

QT interval prolongation, predisposing to ventricular tachyarrhythmia, has frequently been observed in patients with liver cirrhosis. During liver transplantation (LT) surgery, electrolyte imbalance and hemodynamic instability may affect QT interval changes. We evaluated the alterations in QT parameters at each stage of LT surgery.

METHODS

We assessed 50 living donor LT recipients without overt heart disease for the corrected QT (QTc) and the interval from peak to the end of the T wave (T(p-e)) automatically using Bazett's formula with LabChart software. QT parameters, laboratory and hemodynamic data were simultaneously collected in the following stages of LT: before anesthetic induction (baseline), pre-anhepatic, anhepatic, 1 hour postreperfusion, and after hepatic artery anastomosis. Recipients were allocated into 2 groups according to their baseline QTc: ≥440 versus <440 msec.

RESULTS

QTc progressively rose from the pre-anhepatic stage remaining prolonged in each stage of LT surgery compared with the baseline. In the anhepatic stage, 54% of recipients showed marked prolongation of QTc ≥500 msec (522 ± 14), which indicated the potential for a fatal ventricular dysrhythmia: 77% and 36% in groups with QTc ≥440 and <440 msec, respectively. As opposed to changes in QTc, T(p-e) in the anhepatic stage decreased significantly; however, it returned to the baseline level in the neohepatic stage.

CONCLUSION

A prolonged QTc interval (≥500 msec) was frequently observed throughout the procedure of LT, even among patients with baseline QTc <440 msec, emphasizing the importance of optimizing electrolyte balance and hemodynamic status to reduce greater risk of perioperative arrhythmias.