Successful resuscitation after hyperkalemic cardiac arrest during liver transplantation by converting veno-venous bypass to veno-arterial ECMO

Anesthesia for Combined Heart-Liver Transplantation: A Narrative Review

In 1984, 21 years after the first liver transplantation, Thomas Starzl achieved a milestone by performing the world's first combined heart-liver transplantation. While still uncommon, the practice of combined heart-liver transplants is on the rise globally. In this review, the authors delve into the current literature on this procedure, highlighting the evolving landscape and key considerations for anesthesiologists. Over the years, there has been a remarkable increase in the number of combined heart-liver transplantations conducted worldwide. This surge is largely attributed to the growing population of adult survivors with single-ventricle physiology, palliated with a Fontan procedure, who later present with late Fontan failure and Fontan-associated liver disease. Research indicates that combined heart-liver transplantation is an effective treatment option, with reported outcomes comparable with isolated heart or liver transplants. Managing anesthesia during a combined heart-liver transplant procedure is challenging, especially in the context of underlying Fontan physiology. International experience in this field remains somewhat limited, with most techniques derived from expert opinions or experiences with single-organ heart and liver transplants. These procedures are highly complex and performed infrequently. As the number of combined heart-liver transplants continues to rise globally, there is a growing need for clear guidance on periprocedural surgical and anesthetic management. Anesthesiologists overseeing these patients must consider multiple factors, balancing various comorbidities with significant hemodynamic and metabolic shifts. An increase in (multicenter) studies focusing on specific interventions to enhance patient and organ outcomes is anticipated in the coming years.

The applications of ECMO in liver transplant recipients

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.

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

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.

Intestinal ischemia‑reperfusion induces the release of IL‑17A to regulate cell inflammation, apoptosis and barrier damage

Intestinal ischemia-reperfusion (I/R) injury promotes the release of IL-17A, and previous studies have indicated that TGF-β activated kinase 1 (TAK1) is an important signaling molecule in the regulatory function of IL-17A. The present study aimed to explore the potential effects of IL-17A release in intestinal I/R injury, and to investigate the underlying regulatory mechanisms. Initially, the expression levels of TAK1 and JNK in a hypoxia/reoxygenation model were determined, and the effects of TAK1-knockdown on JNK phosphorylation and the viability, inflammation, apoptosis and barrier function of Caco-2 cells were assessed using Cell Counting Kit-8, reverse transcription-quantitative PCR, TUNEL and transepithelial electrical resistance assays, respectively. Subsequently, an antibody targeting IL-17A was used, and the effects of the IL-17A antibody on the expression levels of TAK1 as well as cell viability, inflammation, apoptosis and barrier function were determined. The results of the present study demonstrated that TAK1-knockdown markedly reduced JNK phosphorylation and improved the levels of cell viability, inflammation, apoptosis and barrier function via the MAPK signaling pathway. In addition, treatment with the IL-17A antibody inhibited the expression of TAK1, and reversed the aforementioned effects of TAK1 on Caco-2 cells. In conclusion, intestinal I/R induces the release of IL-17A to regulate cell viability, inflammation, apoptosis and barrier damage via the TAK1/MAPK signaling pathway.

The evolving role of ECMO in liver transplantation

PURPOSE OF REVIEW

To review the indications for extra-corporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients and their optimal management on ECMO.

RECENT FINDINGS

Recent studies have reported a 30-40% survival rate among LT recipients that receive ECMO. Increasingly, case reports have documented successful outcomes of LT performed for patients on preoperative ECMO. Outcomes appear to be superior with patients in the immediate peri-LT period with reversible causes of severe, acute respiratory, and/or cardiovascular collapse. Mortality is most commonly secondary to infection. Volume optimization with CRRT may improve outcomes and perfusion to the graft, especially for patients on veno-arterial ECMO. There is little consensus on management of anticoagulation in these patients, but it can likely be held temporarily when the patient is coagulopathic and/or experiencing bleeding complications.

SUMMARY

ECMO should be considered in the peri-LT period for patients with severe, acute, and reversible causes of respiratory and/or cardiovascular collapse, with acceptable outcomes in patients that would otherwise not be expected to survive. Management of the post-LT patient on ECMO is challenging with a slowly enlarging body of literature to inform decision making.