Complications related to intraoperative transesophageal echocardiography in liver transplantation

Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE

BACKGROUND

Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking.

METHODS

This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed.

RESULTS

Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources.

CONCLUSIONS

The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

Utility of transesophageal echocardiography during orthotopic liver transplantation: A narrative review

Orthotopic liver transplantation (OLT) is the standard of care for patients suffering from end stage liver disease (ESLD). This is a high-risk procedure with the potential for hemorrhage, large shifts in preload and afterload, and release of vasoactive mediators that can have profound effects on hemodynamic equilibrium. In addition, patients with ESLD can have preexisting coronary artery disease, cirrhotic cardiomyopathy, porto-pulomary hypertension and imbalanced coagulation. As cardiovascular involvement is invariable and patient are at an appreciable risk of intraoperative cardiac arrest, Trans esophageal echocardiography (TEE) is increasingly becoming a routinely utilized monitor during OLT in patients without contraindications to its use. A comprehensive TEE assessment performed by trained operators provides a wealth of information on baseline cardiac function, while a focused study specific for the ESLD patients can help in prompt diagnosis and treatment of critical events. Future studies utilizing TEE will eventually optimize examination safety, quality, permit patient risk stratification, provide intraoperative guidance, and allow for evaluation of graft vasculature.

Transesophageal echocardiography-associated gastrointestinal injuries: systematic review and pooled rates of gastrointestinal injuries

Upper gastrointestinal (GI) injuries are associated with transesophageal echocardiography (TEE) complications. We reviewed rates and various types of complications with GI injuries. A comprehensive literature search using five databases was conducted. Pooled rates were calculated for overall injuries, pooled GI complications, lacerations, and perforations with a 95% confidence interval (CI). A total of 26 studies involving 55,319 patients met inclusion criteria. The overall rate of adverse events was 0.51% (95% CI 0.3% to 0.7%). Bleeding was the most commonly reported adverse event, followed by dysphagia and lacerations. The highest rate of adverse events was observed in liver transplant patients (1.35%), followed by critically ill patients in the intensive care unit (1.1%), hospitalized patients (1.1%), patients undergoing intraoperative TEE (0.7%), and those undergoing cardiac procedures (0.67%). The pooled complication rate for bleeding was 0.17% (95% CI 0.1% to 0.3%), while odynophagia/dysphagia had a rate of 0.27% (95% CI -0.1% to 0.5%) and lacerations had a rate of 0.12% (95% CI -0.1% to 0.5%). A subgroup analysis comparing variceal and nonvariceal cohorts from three studies showed no significant difference in bleeding rates. Our study findings showed a low risk of esophageal injury in patients undergoing TEE.

Incidence of Gastrointestinal Bleeding After Transesophageal Echocardiography Use in Orthotopic Liver Transplantation

The risk of upper gastrointestinal bleeding (UGIB) after transesophageal echocardiography (TEE) in patients with high grade esophageal varices (EV) that are undergoing Orthotopic Liver transplantation (OLT) is poorly understood. This was a retrospective single-centre cohort study in all patients that underwent OLT at Queen Elizabeth Hospital Birmingham between September 2016 and September 2018. The primary outcome was to determine the incidence of UGIB in patients that have undergone OLT with EV that received TEE. 401 patients were included in the study, of which 320 (80%) received TEE. The incidence of post-operative UGIB in patients that received TEE was 1.6% (5/320) in the entire cohort: 2.7% (4/149) in patients with no evidence of EV and 0.6% (1/171) in patients with EV. UGIB occurred in 1 patient with grade 2 EV and did not occur in patients with grade 1 or 3 EV. The incidence of UGIB in patients that received TEE was not statistically different to patients that did not: 1.6% (5/320) vs. 3.7% (3/81) p = 0.218. In conclusion, in patients that underwent OLT, intra-operative TEE use was associated with low rates of UGIB, even in cohorts with high grade EV. This suggests that TEE is a relatively safe method of haemodynamic monitoring in patients undergoing OLT.

What is the optimal anesthetic monitoring regarding immediate and short-term outcomes after liver transplantation?-A systematic review of the literature and expert panel recommendations

BACKGROUND

Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes.

OBJECTIVES

To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short-term outcomes after orthotopic liver transplant (OLT).

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring, (2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908).

RESULTS

Of 2619 articles screened 16 were included. Studies were small, retrospective, and observational. Vascular access studies demonstrated low rates of insertion complications. TEE studies demonstrated low rates of esophageal hemorrhage. One study found lower hospital-LOS and 30-day mortality in patients monitored with both PAC and TEE. Other monitoring studies were heterogenous in design and outcomes. Temperature studies showed increased blood transfusion and ventilation times in hypothermic groups.

CONCLUSIONS

Recommendations were made for; routine arterial and CVP monitoring as a minimum standard of practice, consideration of discrepancy between peripheral and central arterial BP in patients with hemodynamic instability and high vasopressor requirements, and routine use of high flow cannulae while monitoring for extravasation and hematoma formation. Availability and expertise in PAC and/or TEE monitoring is strongly recommended particularly in hemodynamic instability, portopulmonary HT and/or cardiac dysfunction. TEE use is recommended as an acceptable risk in patients with treated esophageal varices and is an effective diagnostic tool for emergency cardiovascular collapse. Maintenance of intraoperative normothermia is strongly recommended.

Role of endoscopic evaluation prior to diagnostic transesophageal echocardiography: Is it necessary?

Background and Aim

Esophagogastroduodenoscopy (EGD) is often performed prior to transesophageal echocardiogram (TEE) to evaluate for esophageal pathologies. Although TEE is a safe procedure, some contraindications exist, such as esophageal varices. The incidence of bleeding with TEE is <0.01%, which questions the need for this routine invasive procedure prior to TEE. We sought to characterize patients in whom pre‐TEE endoscopy was requested to determine its clinical utility and identify those that would most benefit.

Methods

We retrospectively studied patients who underwent EGD for TEE clearance between January 2014 and October 2019. We assessed how often EGD changed management and complications after TEE in those with EGD abnormalities.

Results

Eighty‐three patients were included. Twenty‐three percent had prior GI bleed, 63% had cirrhosis, 18% had known varices, and 7% had prior variceal bleed. The most common EGD findings were varices (33%). Eighty‐one percent proceeded with TEE. Reasons for TEE deferral included varices (12.5%), high‐risk bleeding lesion (12.5%), and mechanical abnormality (12.5%). In the majority (37.5%), TEE was deemed no longer indicated. No patient undergoing TEE had significant hemoglobin drop or overt bleeding. The most common reason for not performing TEE was unrelated to EGD findings: lack of ongoing indication for TEE.

Conclusion

Based on our study, EGD is likely not needed for TEE clearance in patients with varices or prior GI bleed. Given that data are limited in patients with abnormalities such as strictures, EGD may still be warranted for these patients. Further studies to identify which patients will benefit from pre‐TEE endoscopy are warranted.

Bleeding Complications from Transesophageal Echocardiography for Liver Transplantation: A Systematic Review

Transesophageal echocardiography (TEE) for liver transplant has historically been avoided due to concern it may cause bleeding from esophageal varices. However, several recent studies, as well as increasing clinical experience, have indicated that it may be safe in many circumstances. We performed a systematic review of the literature to identify and summarize studies reporting complications in patients having TEE during liver transplant. Studies were identified by searching relevant key terms on PubMed as well as citation searching in relevant reviews. We identified 6 studies between 1996 and 2015 which evaluated complications of TEE during liver transplant. They reported an overall bleeding complication rate between .3% and 2.8% and a major bleeding complication rate between .0% and .8%. Most of the major bleeds had identifiable high-risk features such as recent variceal bleeding or banding. Review of the literature suggests that TEE may be safely used in patients undergoing liver transplantation, even with known varices, with a complication rate similar to that of all patients undergoing TEE. However, the risks of TEE may outweigh the potential benefits among patients undergoing liver transplant with particular high-risk features.

Systematic review with meta-analysis: incidence of variceal hemorrhage in patients with cirrhosis undergoing transesophageal echocardiography

BACKGROUND

The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis.

AIM

To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE.

METHODS

Two reviewers searched Ovid MEDLINE, MEDLINE In-Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model.

RESULTS

We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n = 3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n = 1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post-TEE was 0.37% (95% CI 0.04-0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies.

CONCLUSIONS

The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

Balancing the tug of war: intraoperative and postoperative management of multiorgan transplantation

PURPOSE OF REVIEW

Multiorgan heart transplants (MOHT) have steadily increased and account for approximately 4% of all heart transplants performed. Although long-term outcomes of MOHT are similar to heart transplant alone, perioperative management remains an issue with nearly double the rate of prolonged hospitalization. Better understanding of hemodynamic environments encountered and appropriate therapeutic targets can help improve perioperative management.

RECENT FINDINGS

Accurate and precise hemodynamic monitoring allows for early identification of complications and prompt assessment of therapeutic interventions. This can be achieved with a multimodal approach using traditional monitoring tools, such a pulmonary artery catheter and arterial line in conjunction with transesophageal echocardiography. Specific targets for optimizing graft perfusion are determined by phase of surgery and organ combination. In some circumstances, the surgical sequence of transplant can help mitigate or avoid certain detrimental hemodynamic environments.

SUMMARY

With better understanding of the array of hemodynamic environments that can develop during MOHT, we can work to standardize hemodynamic targets and therapeutic interventions to optimize graft perfusion. Effectively navigating this perioperative course with multimodal monitoring including transesophageal echocardiography can mitigate impact of complications and reduce prolonged hospitalization associated with MOHT.

Incidence of Gastrointestinal Bleeding after Transesophageal Echocardiography in Patients with Gastroesophageal Varices: A Systematic Review and Meta-Analysis

BACKGROUND

Transesophageal echocardiography (TEE) is useful for cardiac assessment and intraoperative monitoring. However, the safety of TEE in patients with cirrhosis and gastroesophageal varices has remained uncertain. The aim of this meta-analysis was to determine the incidence of gastrointestinal bleeding after TEE in patients with varices. The secondary objectives were to compare bleeding risks between patients with and without varices and to determine the incidence of TEE-related esophageal perforation and mortality.

METHODS

A systematic literature search was conducted on MEDLINE, Embase, and the Cochrane Library using the terms "transesophageal echocardiography," "varices," "bleeding," and related terms. Articles describing the incidence of post-TEE bleeding in patients with varices were included. Non-English-language articles were excluded. Risk of bias and level of evidence were assessed using validated scales. The pooled weighted incidence of gastrointestinal bleeding and the risk difference in bleeding were calculated using a random-effects model.

RESULTS

Five hundred and sixty-nine articles were identified initially, and 10 articles (comprising of 908 patients) were included. The incidence of post-TEE bleeding in patients with varices was 0.84% (95% CI, 0.34% to 1.56%). When stratified by indication for TEE, the pooled incidence of bleeding was 0.68% (95% CI, 0.11% to 1.63%) for intraoperative TEE and 1.03% (95% CI, 0.23% to 2.29%) for diagnostic TEE. No cases of esophageal perforation or mortality were reported. Six studies included comparator groups of patients without varices, and the bleeding risk was comparable between patients with and those without varices (risk difference, 0.26%; 95% CI, -0.80% to 1.32%; I² = 0%; P = .88). Eight studies had moderate or high risk for bias, and the overall level of evidence was low.

CONCLUSIONS

TEE appears to be associated with low gastrointestinal bleeding incidence in patients with gastroesophageal varices. Nonetheless, results should be treated with caution because of bias and low level of evidence. Large-scale high-quality studies will be required to confirm the safety of TEE in patients with gastroesophageal varices.

Preoperative echocardiography as a prognostic tool for liver transplant in patients with hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) presents with a hypertrophied left ventricle (LV). It is often associated with LV outflow tract obstruction (LVOTO) and a risk for sudden death. This study aimed to describe outcomes of patients with HCM who underwent liver transplant (LT).

METHODS

A retrospective review was conducted for patients diagnosed with HCM undergoing LT. Patient characteristics, preoperative echocardiography results, HCM risk of sudden cardiac death prediction model score, and 5-year mortality were examined. A univariable Cox proportional hazards model was used to evaluate the association between risk factors and 5-year mortality. All tests were two-sided with the alpha level set at .05.

RESULTS

Twenty-nine patients were included in the analysis. Six patients (21%) had a perioperative cardiopulmonary complication. The 5-year survival rate was 61% (95% CI, 45-82). The analyzed risk factors showed that 5-year post-LT survival was significantly predicted by maximal LV outflow tract gradient at rest > 60 mmHg (hazard ratio, 1.04 [95% CI, 1.01-1.06]).

CONCLUSIONS

Preoperative LV outflow tract resting gradient > 60 mmHg was associated with 5-year post-LT mortality. The results suggest the severity of LVOTO identified by echocardiography is a prognostic tool for patients with HCM after LT.

Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA

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.

Bleeding Outcomes Following Transesophageal Echocardiography in Patients With Cirrhosis and Esophageal Varices

Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this study is to compare the risk of gastrointestinal bleeding following TEE among cirrhotic patients with and without endoscopically-documented esophageal varices. This is a retrospective analysis of patients with cirrhosis who underwent upper endoscopy within 4 years of TEE at five institutions between January 2000 and March 2020. Primary outcome was overt gastrointestinal bleeding. Secondary outcomes were hemoglobin decline by at least 2 g/dL or blood transfusion within 48 hours following TEE. Of the 191 patients, 79 (41.4%) had esophageal varices (30.4% large). No patient experienced a primary outcome. Secondary outcomes occurred in 52 (27.2%): 28 (35.4%) with esophageal varices and 24 (21.4%) without varices. After propensity-score covariate adjustment, the odds ratio for a secondary outcome in patients with esophageal varices was 1.49 (95% confidence interval 0.74-2.99). Restricting analysis to those who underwent endoscopy within 1 year of TEE did not significantly alter results. The risk of a secondary outcome was identical between patients who had upper endoscopy prior (27.5%) versus subsequent (26.7%; P = 1.00) to TEE. Conclusions: Among patients with cirrhosis, there was no overt gastrointestinal bleeding after TEE. The likelihood of a 2 g/dL decline in hemoglobin or blood transfusion within 48 hours following TEE was not significantly higher in patients with esophageal varices after controlling for confounders. Patients who underwent upper endoscopy before TEE did not manifest a lower risk of secondary outcomes versus those who had endoscopy after TEE, suggesting that routine preprocedural endoscopy is of marginal utility.

Risk Factors and Outcomes of Intracardiac Thrombosis During Orthotopic Liver Transplantation

BACKGROUND

Intracardiac thrombosis incidence during orthotopic liver transplantation is estimated at 0.36% to 6.2% with mortality up to 68%. We aimed to evaluate risk factors and outcomes related to intracardiac thrombosis during orthotopic liver transplantation.

MATERIALS AND METHODS

A comprehensive retrospective data review of 388 patients who underwent orthotopic liver transplantation at an urban transplant center from January 2013 to October 2016 was obtained.

RESULTS

Six patients were found to have documented intracardiac thrombosis; 4 cases were recognized during the reperfusion stage and 1 during pre-anhepatic stage. All allografts were procured from decreased donors with a median donor age of 44 years (interquartile range, 35.25-49.75) and the cause of death was listed as cerebrovascular accident in 5 donors. Preoperative demographic, clinical, laboratory, and historical risk factors did not differ in patients with thrombosis. None had a prior history of trans-jugular intrahepatic portosystemic shunt or gastrointestinal bleeding. Three patients had renal injury, but no intraoperative hemodialysis was performed. Transesophageal echocardiographic findings included elevated pulmonary artery pressure (1/6), right ventricular strain (1/6), and pulmonary artery thrombus (1/6). Three patients died intraoperatively. Tissue plasminogen activator alone was given to 1 patient who did not survive, intravenous heparin only to 1 patient with resolution, and a combination of both was used in 2 patients with clot resolution achieved.

CONCLUSION

Cardiac thrombosis should be considered in patients having hemodynamic compromise during liver transplantation. Transesophageal echocardiography is a useful diagnostic tool. Intracardiac thrombosis treatment remains challenging; however, using both thrombolytics and heparin could achieve better results.

A Comprehensive Review of Transesophageal Echocardiography During Orthotopic Liver Transplantation

Orthotopic liver transplantation (OLT) is characterized by significant hemodynamic disturbances and anesthetic challenges. Intraoperative transesophageal echocardiography (TEE) can be used to guide management during these procedures. This review examines the role of echocardiography during OLT, presents common TEE findings during each phase of OLT, and discusses the benefits demonstrated with TEE use and the safety of TEE in this patient population. Finally, the authors propose an algorithm for the safe use of TEE during OLT.

Comparative Effectiveness and Harms of Intraoperative Transesophageal Echocardiography in Noncardiac Surgery: A Systematic Review

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.

Prolonged Intraoperative Cardiac Resuscitation Complicated by Intracardiac Thrombus in a Patient Undergoing Orthotopic Liver Transplantation

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.