1
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Saner FH, Scarlatescu E, Broering DC, Bezinover D. The Yin and the Yang of Hemostasis in End-Stage Liver Disease. J Clin Med 2023; 12:5759. [PMID: 37685826 PMCID: PMC10488973 DOI: 10.3390/jcm12175759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) are prone to thromboses both while on the waiting list and in the perioperative period. This hypercoagulability is associated with significant endothelial dysfunction (ED) due to nitric oxide dysregulation. ED and increased thrombin generation are the main factors responsible for this hypercoagulability. Sepsis alone can significantly alter a patient's coagulation profile. In combination with ESLD, however, sepsis or septic shock are responsible for very complex changes. This makes both the assessment and management of coagulation in septic patients with ESLD very challenging. Viscoelastic testing (VET) is the preferred method of coagulation management in patients with cirrhosis because, as with standard laboratory testing, VET can assess the entire coagulation system including the interaction between both pro- and anticoagulants and platelets.
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Affiliation(s)
- Fuat H. Saner
- King Faisal Specialist Hospital & Research Center, Organ Transplant Center of Excellence, Riyadh 11564, Saudi Arabia;
| | - Ecaterina Scarlatescu
- Department of Anesthesia and Intensive Care Medicine III, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Anesthesia and Intensive Care Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Dieter Clemens Broering
- King Faisal Specialist Hospital & Research Center, Organ Transplant Center of Excellence, Riyadh 11564, Saudi Arabia;
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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2
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Kumar N, Flores AS, Mitchell J, Hussain N, Kumar JE, Wang J, Fitzsimons M, Dalia AA, Essandoh M, Black SM, Schenk AD, Stein E, Turner K, Sawyer TR, Iyer MH. Intracardiac thrombosis and pulmonary thromboembolism during liver transplantation: A systematic review and meta-analysis. Am J Transplant 2023; 23:1227-1240. [PMID: 37156300 DOI: 10.1016/j.ajt.2023.04.029] [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: 10/20/2022] [Revised: 04/13/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
Intracardiac thrombosis and/or pulmonary thromboembolism (ICT/PE) is a rare but devastating complication during liver transplantation. Its pathophysiology remains poorly understood, and successful treatment remains a challenge. This systematic review summarizes the available published clinical data regarding ICT/PE during liver transplantation. Databases were searched for all publications reporting on ICT/PE during liver transplantation. Data collected included its incidence, patient characteristics, the timing of diagnosis, treatment strategies, and patient outcomes. This review included 59 full-text citations. The point prevalence of ICT/PE was 1.42%. Thrombi were most often diagnosed during the neohepatic phase, particularly at allograft reperfusion. Intravenous heparin was effective in preventing early-stage thrombus from progressing further and restoring hemodynamics in 76.32% of patients it was utilized for; however, the addition of tissue plasminogen activator or sole use of tissue plasminogen activator offered diminishing returns. Despite all resuscitation efforts, the in-hospital mortality rate of an intraoperative ICT/PE was 40.42%, with nearly half of these patients dying intraoperatively. The results of our systematic review are an initial step for providing clinicians with data that can help identify higher-risk patients. The clinical implications of our results warrant the development of identification and management strategies for the timely and effective treatment of these tragic occurrences during liver transplantation.
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Affiliation(s)
- Nicolas Kumar
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antolin S Flores
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Justin Mitchell
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julia E Kumar
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jack Wang
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Michael Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sylvester M Black
- Division of Transplantation Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Austin D Schenk
- Division of Transplantation Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Erica Stein
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Katja Turner
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tamara R Sawyer
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan, USA
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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3
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Kataria S, Juneja D, Singh O. Approach to thromboelastography-based transfusion in cirrhosis: An alternative perspective on coagulation disorders. World J Gastroenterol 2023; 29:1460-1474. [PMID: 36998429 PMCID: PMC10044856 DOI: 10.3748/wjg.v29.i9.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023] Open
Abstract
Viscoelastic tests, specifically thromboelastography and rotational thromboelastometry, are increasingly being used in the management of postoperative bleeding in surgical intensive care units (ICUs). However, life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs, especially those with underlying liver dysfunction. Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications. Compared to conventional coagulation tests, a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices, which may aid physicians in making a rapid diagnosis and instituting early interventions. These tests may help predict bleeding and rationalize the use of blood products in these patients.
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Affiliation(s)
- Sahil Kataria
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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4
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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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5
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Jamil O, Fung J, Kelly D, Azzam R. Perioperative fatal pulmonary embolism in a pediatric liver transplant recipient. Pediatr Transplant 2021; 25:e14017. [PMID: 33772990 DOI: 10.1111/petr.14017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 11/27/2022]
Abstract
Patients with cirrhotic liver disease are in a state of fluctuating hemostatic balance. Hepatic synthetic dysfunction is commonly complicated by coagulation disorders that constitute an important parameter of most prognostic scores. The dominant feature of this dysfunction is bleeding tendencies, but cirrhotic patients may also exhibit inappropriate clotting and pro-coagulation placing them at risk for thromboembolism. We present a case of perioperative fatal pulmonary embolism in an 8-year-old patient with biliary cirrhosis secondary to drug-induced vanishing bile duct syndrome undergoing a deceased donor liver transplant. The massive pulmonary embolism occurred intra-operatively after reperfusion of the donor liver. Despite the initiation of extracorporeal membrane oxygenation, the postoperative course was complicated by bleeding and the patient expired. This unique case highlights the need for venous thromboembolism prevention by screening and prophylaxis prior to liver transplant in at least a subpopulation of pediatric patients. While the risk of thrombosis postoperatively in pediatrics patients is well known, the preoperative risk is less frequently described and deserves attention and practice changing action.
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Affiliation(s)
- Omar Jamil
- Departments of Internal Medicine and Pediatrics, University of Chicago, Chicago, IL, USA
| | - John Fung
- Department of Surgery, Section of Transplant Surgery, University of Chicago, Chicago, IL, USA
| | - Dympna Kelly
- Department of Surgery, Section of Transplant Surgery, University of Chicago, Chicago, IL, USA
| | - Ruba Azzam
- Department of Pediatrics, Section of Pediatric Gastroenterology and Hepatology, University of Chicago, Chicago, IL, USA
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6
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Pietri LD, Montalti R, Bolondi G, Serra V, Benedetto FD. Intraoperative thromboelastography as a tool to predict postoperative thrombosis during liver transplantation. World J Transplant 2020; 10:345-355. [PMID: 33312895 PMCID: PMC7708883 DOI: 10.5500/wjt.v10.i11.345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/28/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thromboembolic complications are relatively common causes of increased morbidity and mortality in the perioperative period in liver transplant patients. Early postoperative portal vein thrombosis (PVT, incidence 2%-2.6%) and early hepatic artery thrombosis (HAT, incidence 3%-5%) have a poor prognosis in transplant patients, having impacts on graft and patient survival. In the present study, we attempted to identify the predictive factors of these complications for early detection and therefore monitor more closely the patients most at risk of thrombotic complications.
AIM To investigate whether intraoperative thromboelastography (TEG) is useful in detecting the risk of early postoperative HAT and PVT in patients undergoing liver transplantation (LT).
METHODS We retrospectively collected thromboelastographic traces, in addition to known risk factors (cold ischemic time, intraoperative requirement for red blood cells and fresh-frozen plasma transfusion, prolonged operating time), in 27 patients, selected among 530 patients (≥ 18 years old), who underwent their first LT from January 2002 to January 2015 at the Liver University Transplant Center and developed an early PVT or HAT (case group). Analyses of the TEG traces were performed before anesthesia and 120 min after reperfusion. We retrospectively compared these patients with the same number of nonconsecutive control patients who underwent LT in the same study period without developing these complications (1:1 match) (control group). The chosen matching parameters were: Patient graft and donor characteristics [age, sex, body mass index (BMI)], indication for transplantation, procedure details, United Network for Organ Sharing classification, BMI, warm ischemia time (WIT), cold ischemia time (CIT), the volume of blood products transfused, and conventional laboratory coagulation analysis. Normally distributed continuous data are reported as the mean ± SD and compared using one-way Analysis of Variance (ANOVA). Non-normally distributed continuous data are reported as the median (interquartile range) and compared using the Mann-Whitney test. Categorical variables were analyzed with Chi-square tests with Yates correction or Fisher’s exact test depending on best applicability. IBM SPSS Statistics version 24 (SPSS Inc., Chicago, IL, United States) was employed for statistical analysis. Statistical significance was set at P < 0.05.
RESULTS Postoperative thrombotic events were identified as early if they occurred within 21 d postoperatively. The incidence of early hepatic artery occlusion was 3.02%, whereas the incidence of PVT was 2.07%. A comparison between the case and control groups showed some differences in the duration of surgery, which was longer in the case group (P = 0.032), whereas transfusion of blood products, red blood cells, fresh frozen plasma, and platelets, was similar between the two study groups. Thromboelastographic parameters did not show any statistically significant difference between the two groups, except for the G value measured at basal and 120’ postreperfusion time. It was higher, although within the reference range, in the case group than in the control group (P = 0.001 and P < 0.001, respectively). In addition, clot lysis at 60 min (LY60) measured at 120’ postreperfusion time was lower in the case group than in the control group (P = 0.035). This parameter is representative of a fibrinolysis shutdown (LY60 = 0%-0.80%) in 85% of patients who experienced a thrombotic complication, resulting in a statistical correlation with HAT and PVT.
CONCLUSION The end of surgery LY60 and G value may identify those recipients at greater risk of developing early HAT or PVT, suggesting that they may benefit from intense surveillance and eventually anticoagulation prophylaxis in order to prevent these serious complications after LT.
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Affiliation(s)
- Lesley De Pietri
- Department of General Surgery, Division of Anaesthesiology and Intensive Care Unit, Nuovo Ospedale Civile di Sassuolo, Sassuolo 41049, Modena, Italy
| | - Roberto Montalti
- Department of Public Health, Hepato-Pancreato-Biliary Surgery Section, Federico II University of Naples, Napoli 80138, Italy
| | - Giuliano Bolondi
- Surgery and Trauma Department, Intensive Care Unit, Ospedale Bufalini Cesena, Cesena 47521, Italy
| | - Valentina Serra
- Surgery Department, Hepato-Pancreato-Biliary Surgery, Surgical Oncology and Liver Transplantation Unit, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio Emilia, Modena 41125, Italy
| | - Fabrizio Di Benedetto
- Surgery Department, Hepato-Pancreato-Biliary Surgery, Surgical Oncology and Liver Transplantation Unit, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio Emilia, Modena 41125, Italy
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7
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Sharma S, Sonny A, Dalia AA, Karamchandani K. Acute heart failure after liver transplantation: A narrative review. Clin Transplant 2020; 34:e14079. [PMID: 32941661 DOI: 10.1111/ctr.14079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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8
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Massive Pulmonary Artery Thromboembolism in a Liver Transplant Recipient: Case Study and Literature Review. Transplant Proc 2020; 52:2795-2801. [PMID: 32713815 DOI: 10.1016/j.transproceed.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/04/2020] [Indexed: 11/20/2022]
Abstract
The hypercoagulable state in liver transplant recipients that may manifest as abnormal thrombus formation in large vessel structures, such as cardiac chambers and the pulmonary arteries, poses a substantial threat for the patient and graft survival. Massive pulmonary embolism is a rare, albeit potentially lethal, complication that may occur at any stage of liver transplant surgery. In this study, we present the case of a major perioperative thromboembolic event in a liver transplant recipient that had taken place in the early post-transplant period during the second-look surgery that was then successfully treated by catheter-directed clot removal. We will attempt to identify potential factors that may have been associated with abnormal thrombus formation.
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9
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Zanetto A, Senzolo M, Blasi A. Perioperative management of antithrombotic treatment. Best Pract Res Clin Anaesthesiol 2020; 34:35-50. [PMID: 32334786 DOI: 10.1016/j.bpa.2020.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 01/10/2023]
Abstract
End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain.
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10
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Groose MK, Aldred BN, Mezrich JD, Hammel LL. Risk Factors for Intracardiac Thrombus During Liver Transplantation. Liver Transpl 2019; 25:1682-1689. [PMID: 31119833 DOI: 10.1002/lt.25498] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
Intracardiac thrombus (ICT) is an intraoperative complication with high mortality that occurs during orthotopic liver transplantation (OLT). Patients with end-stage liver disease have compromised coagulation pathways, and when combined with stressors of surgery, thrombi can form. However, it is unknown which patients are most likely to develop ICT. We performed a retrospective cohort study of all OLT patients at our hospital from 2010 to 2017 to identify risk factors for ICT. An analysis was performed with conventional bivariate tests and logistic regression. The incidence of ICT during OLT was 4.2% (22/528) with a 45.5% (10/22) mortality. Patients who developed ICT had higher physiologic Model for End-Stage Liver Disease scores at the time of transplant (25.1 versus 32.4; P = 0.004), received grafts from donors with a higher body mass index (28.1 versus 32.2 kg/m2 ; P = 0.007), and had longer intraoperative warm ischemia times (53.1 versus 67.5 minutes; P = 0.001). The odds of developing ICT were significantly lower after administration of intravenous (IV) heparin prior to inferior vena cava (IVC) clamping compared with no administration of heparin (odds ratio, 0.25; 95% confidence interval, 0.08-0.75; P = 0.01). In conclusion, the incidence of ICT at our institution is higher than previously reported, which may be explained by our routine use of transesophageal echocardiography. Although many factors associated with ICT in this study are nonmodifiable, administration of IV heparin prior to IVC cross-clamping is modifiable and was found to be protective. Further studies will be needed to confirm findings and ultimately aid in preventing these lethal events.
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Affiliation(s)
- Molly K Groose
- Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI
| | - Breanna N Aldred
- Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI
| | - Joshua D Mezrich
- Departments of Surgery, Transplantation Division, University of Wisconsin Hospital, Madison, WI
| | - Laura L Hammel
- Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI
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11
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Significant Hyperfibrinolysis in a Patient With Intracardiac Thrombosis: To Give Antifibrinolytics or Not? Transplant Direct 2019; 5:e431. [PMID: 30882036 PMCID: PMC6411226 DOI: 10.1097/txd.0000000000000875] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/12/2018] [Accepted: 01/25/2019] [Indexed: 11/26/2022] Open
Abstract
The hemostatic system is a delicate balance between the coagulation, anticoagulation, and fibrinolytic systems and is responsible for preventing both hemorrhage and thrombosis. End stage liver disease is characterized by a rebalanced hemostatic system that is fragile and easily tipped towards either hemorrhage or thrombosis. During an orthotopic liver transplantation, patients are exposed to a wide variety of factors that can shift them from a hypercoagulable state to a hypocoagulable state almost instantaneously. The treatment for these two disease states contradict each other, and therefore patients in this condition can be extremely difficult to manage. Here, we present a patient who underwent an orthotopic liver transplantation and suffered an intracardiac thrombosis shortly after reperfusion of the donor graft, that resolved with supportive care, who then went on to develop severe persistent hyperfibrinolysis and massive hemorrhage that was successfully treated with an antifibrinolytic agent.
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12
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Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplant Direct 2018; 4:e403. [PMID: 30534594 PMCID: PMC6233657 DOI: 10.1097/txd.0000000000000843] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/23/2018] [Indexed: 12/14/2022] Open
Abstract
In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.
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13
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Current Hematological Concepts and Viscoelastic-Based Transfusion Practices During Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0203-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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14
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De Pietri L, Montalti R, Nicolini D, Troisi RI, Moccheggiani F, Vivarelli M. Perioperative thromboprophylaxis in liver transplant patients. World J Gastroenterol 2018; 24:2931-2948. [PMID: 30038462 PMCID: PMC6054944 DOI: 10.3748/wjg.v24.i27.2931] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation (LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications (intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors (portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis’’ can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors (venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.
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Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, Reggio Emilia 42123, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Roberto Ivan Troisi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent 185 3K3 9000, Belgium
- Department of Clinical Medicine, Federico II University Naples, Naples 80138, Italy
| | - Federico Moccheggiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
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Raveh Y, Rodriguez Y, Pretto E, Souki F, Shatz V, Ashrafi B, Manmohansigh V, Demos M, Livingstone J, Nasrallah G, Andrews D, Beduschi T, Vianna R, Nicolau-Raducu R. Thrombotic and hemorrhagic complications during visceral transplantation: risk factors, and association with intraoperative disseminated intravascular coagulation-like thromboelastographic qualities: a single-center retrospective study. Transpl Int 2018; 31:1125-1134. [DOI: 10.1111/tri.13281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/09/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Yiliam Rodriguez
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Ernesto Pretto
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Fouad Souki
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Vadim Shatz
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Behrouz Ashrafi
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Vinaya Manmohansigh
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Michael Demos
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Joshua Livingstone
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Georges Nasrallah
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - David Andrews
- Pathology Department; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Thiago Beduschi
- Miami Transplant Institute; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Rodrigo Vianna
- Miami Transplant Institute; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Ramona Nicolau-Raducu
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
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16
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Successful Removal of Intracardiac Thrombus With a Poole Tip Suction Device Through the Inferior Vena Cava of a Patient With Cardiovascular Collapse During Liver Transplant: A Case Report. A A Pract 2018; 10:272-275. [PMID: 29240017 DOI: 10.1213/xaa.0000000000000683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intracardiac thrombus occurs in 1.2%-6.3% of patients undergoing orthotopic liver transplant and is associated with a high mortality rate. The pathophysiology and risk factors for development of this complication are not well understood. No consensus treatment guidelines exist, and specific therapies are associated with serious risks. We present the timely and successful use of a Poole tip surgical suction device advanced into the right atrium through a cavotomy created in the inferior vena cava to remove a large right atrial thrombus during liver transplant. The thrombus was identified with transesophageal echocardiography and was causing cardiovascular collapse.
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18
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Essandoh M. Intracardiac Thrombus Formation During Liver Transplantation: How Do We Prevent This Complication? J Cardiothorac Vasc Anesth 2017; 32:e66-e67. [PMID: 29277302 DOI: 10.1053/j.jvca.2017.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Essandoh
- Department of Anesthesiology, Wexner Medical Center, Ohio State University, Columbus, OH
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19
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Emergent Management of Intracardiac Thrombosis during Liver Transplantation. Case Rep Transplant 2016; 2016:6268370. [PMID: 28070442 PMCID: PMC5192313 DOI: 10.1155/2016/6268370] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/20/2016] [Indexed: 01/28/2023] Open
Abstract
Intraoperative thromboembolism is a well-documented complication associated with orthotopic liver transplantation (OLT) but its identification and intraoperative treatment are still an emerging topic in anesthesia. Intracardiac thrombus during OLT is associated with a high mortality rate. There are only a few reports describing the successful management of thromboembolism during OLT. We describe a case where routine intraoperative transesophageal echocardiography during a live donor liver transplantation enabled early detection of an intracardiac thrombus with subsequent successful heparin treatment. Our case suggests that if an intracardiac thrombus is identified early (before hemodynamic instability occurs), the use of IV heparin may be a safe therapeutic option.
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20
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Dalia AA, Khan H, Flores AS. Intraoperative Diagnosis of Intracardiac Thrombus During Orthotopic Liver Transplantation With Transesophageal Echocardiography: A Case Series and Literature Review. Semin Cardiothorac Vasc Anesth 2016; 21:245-251. [DOI: 10.1177/1089253216677966] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Anesthesia for orthotopic liver transplantation (OLT) is challenging for any anesthesiologist as the patients undergoing this procedure are among the most critically ill. Adding to the underlying complexity of OLT management is the rare complication of an intracardiac thrombus (ICT). Intracardiac thrombi can present following liver allograft reperfusion resulting in high morbidity and mortality. Currently there is no consensus treatment for ICT, and the gold standard for diagnosis is intraoperative transesophageal echocardiography (TEE); these 2 factors lead to a dangerous amalgam of the difficulty in diagnosing and treating the disease. We describe 2 separate cases in detail of ICT formation during OLT that were recognized and diagnosed with intraoperative TEE. These 2 cases highlight the important role of TEE in the management of ICT. A thorough literature review that follows analyzes our current understanding of ICT during OLT and the vital function of TEE by every anesthesiologists regardless of formal TEE training. Broader use of TEE during all OLTs can help narrow the anesthesiologist’s differential diagnosis during the acute phases of transplantation and should be considered in all liver transplant surgeries.
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Affiliation(s)
- Adam A. Dalia
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hisham Khan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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21
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Dalal A. Anesthesia for liver transplantation. Transplant Rev (Orlando) 2016; 30:51-60. [DOI: 10.1016/j.trre.2015.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 09/28/2014] [Accepted: 05/11/2015] [Indexed: 02/08/2023]
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Transfemoral Transcatheter Aortic Valve Replacement for Mixed Aortic Valve Disease in Child’s Class C Liver Disease Prior to Orthotopic Liver Transplantation. Semin Cardiothorac Vasc Anesth 2015; 20:158-62. [DOI: 10.1177/1089253215619235] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The American Association for the Study of Liver Diseases practice guidelines list severe cardiac disease as a contraindication to liver transplantation. Transcatheter aortic valve replacement has been shown to decrease all-cause mortality in patients with severe aortic stenosis who are not considered candidates for surgical aortic valve replacement. We report our experience of liver transplantation in a patient with severe aortic stenosis and moderate aortic insufficiency who underwent transcatheter aortic valve replacement with Child-Pugh Class C disease at a Model For End-Stage Liver Disease score of 29. The patient had a difficult post procedure course that was successfully medically managed. After liver transplantation the patient was discharged to home on postoperative day 11. The combination of cardiac disease and end stage liver disease is challenging but these patients can have a successful outcome despite very severe illness.
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23
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Peiris P, Pai SL, Aniskevich S, Crawford CC, Torp KD, Ladlie BL, Shine TS, Taner CB, Nguyen JH. Intracardiac thrombosis during liver transplant: A 17-year single-institution study. Liver Transpl 2015; 21:1280-5. [PMID: 25939618 DOI: 10.1002/lt.24161] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/07/2015] [Accepted: 04/22/2015] [Indexed: 02/07/2023]
Abstract
Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right- and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.
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Affiliation(s)
- Prith Peiris
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL
| | - Sher-Lu Pai
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | | | - Klaus D Torp
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL
| | - Beth L Ladlie
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | - C Burcin Taner
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL
| | - Justin H Nguyen
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL
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24
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Pai SL, Aniskevich S, Feinglass NG, Ladlie BL, Crawford CC, Peiris P, Torp KD, Shine TS. Complications related to intraoperative transesophageal echocardiography in liver transplantation. SPRINGERPLUS 2015; 4:480. [PMID: 26361581 PMCID: PMC4559558 DOI: 10.1186/s40064-015-1281-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/27/2015] [Indexed: 12/17/2022]
Abstract
Purpose Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated. Methods We retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida). Results Of the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/μL; and fibrinogen, 237.8 (127.6) mg/dL. Conclusion TEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Stephen Aniskevich
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Neil G Feinglass
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Beth L Ladlie
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Claudia C Crawford
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Prith Peiris
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Klaus D Torp
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Timothy S Shine
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
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25
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Feltracco P, Barbieri S, Cillo U, Zanus G, Senzolo M, Ori C. Perioperative thrombotic complications in liver transplantation. World J Gastroenterol 2015; 21:8004-8013. [PMID: 26185371 PMCID: PMC4499342 DOI: 10.3748/wjg.v21.i26.8004] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/30/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023] Open
Abstract
Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation (OLT), the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival. Thromboembolism during OLT is characterized not only by a complex aetiology, but also by unpredictable onset and evolution of the disease. The initiation of a procoagulant process may be triggered by various factors, such as inflammation, venous stasis, ischemia-reperfusion injury, vascular clamping, anatomical and technical abnormalities, genetic factors, deficiency of profibrinolytic activity, and platelet activation. The involvement of the arterial system, intracardiac thrombosis, pulmonary emboli, portal vein thrombosis, and deep vein thrombosis, are among the most serious thrombotic events in the perioperative period. The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis, particularly when these events occur intraoperatively or early after OLT. Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting, many institutions recommend such an approach especially in the subset of patients at high risk. However, the decision of when, how and in what doses to use the various chemical anticoagulants is still a difficult task, since there is no common consensus, even for high-risk cases. The risk of postoperative thromboembolism causing severe hemodynamic events, or even loss of graft function, must be weighed and compared with the risk of an important bleeding. In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurring in the perioperative period, as well as their incidence and clinical features. Moreover, the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.
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26
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Aniskevich S, Ladlie BL, Pai SL, Perry DK, Canabal JM, Taner CB. Postoperative Stroke Following Administration of Intraoperative Recombinant Tissue Plasminogen Activator for the Treatment of Intracardiac Thrombus During Liver Transplantation. J Cardiothorac Vasc Anesth 2014; 29:1314-8. [PMID: 25440645 DOI: 10.1053/j.jvca.2014.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Stephen Aniskevich
- Department of Anesthesiology, Division of Hepatobiliary and Solid Organ Transplant Anesthesiology, Mayo Clinic, Jacksonville, Florida.
| | - Beth L Ladlie
- Department of Anesthesiology, Division of Hepatobiliary and Solid Organ Transplant Anesthesiology, Mayo Clinic, Jacksonville, Florida
| | - Sher-Lu Pai
- Department of Anesthesiology, Division of Hepatobiliary and Solid Organ Transplant Anesthesiology, Mayo Clinic, Jacksonville, Florida
| | - Dana K Perry
- Department of Transplantation, Division of Transplant Surgery, Mayo Clinic, Jacksonville Florida
| | - Juan M Canabal
- Department of Transplantation, Division of Transplant Critical Care, Mayo Clinic, Jacksonville, Florida
| | - C Burcin Taner
- Department of Transplantation, Division of Transplant Surgery, Mayo Clinic, Jacksonville Florida
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27
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Gordon PC, Batty DJ. Haemostatic problems in liver surgery: A review. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2009.10872618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Krzanicki D, Sugavanam A, Mallett S. Intraoperative hypercoagulability during liver transplantation as demonstrated by thromboelastography. Liver Transpl 2013; 19:852-61. [PMID: 23696318 DOI: 10.1002/lt.23668] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
Thrombotic complications are more common in liver disease than might be expected because of the coagulopathy described by conventional coagulation tests. Some of these complications may be life-threatening. The phenomenon of hypercoagulation is associated with complications in many populations, but the incidence in liver transplant recipients is unclear. We performed a retrospective database review of intraoperative thromboelastography (TEG) for 124 liver transplant recipients. We assessed the prevalence of hypercoagulation in this group and investigated the relative frequency of both shortened TEG reaction times (R times) and increased net clot strength (G) values. These findings were correlated with thrombotic complications. At the baseline, the prevalence of high G values was 15.53% on native TEG, and the prevalence of shortened R times was 6.80% on native-heparinase TEG. Patients with cholestatic pathologies had particularly high rates of hypercoagulation (42.9% with primary biliary cirrhosis and 85.7% with primary sclerosing cholangitis), but hypercoagulation was also common in patients with fulminant hepatic failure (50%) and nonalcoholic steatohepatitis (37.5%). There was a poor correlation between the TEG R time and the international normalized (INR), with 37.7% of TEG analyses demonstrating a short R time with an INR > 2. Six of the patients developed early hepatic artery thrombosis (5%); 3 of these patients had TEG evidence of high G values (P = 0.25), and 4 had short R times (not significant). In conclusion, intraoperative TEG evidence of high G values and short R times is relatively common in liver transplantation. It is unclear what bearing this condition has on thrombotic complications. Conventional coagulation tests have no ability to diagnose this condition. It is conceivable that such patients may come to harm if hypercoagulability is unrecognized and, therefore, inappropriately managed.
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Affiliation(s)
- Dominik Krzanicki
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom.
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29
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Intracardiac Thrombosis during Adult Liver Transplantation. Case Rep Transplant 2013; 2013:618352. [PMID: 23984168 PMCID: PMC3741935 DOI: 10.1155/2013/618352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 07/07/2013] [Indexed: 12/27/2022] Open
Abstract
Intracardiac thrombosis (ICT) and pulmonary embolism (PE) during adult liver transplantation are rare but potentially lethal complications. They are often overlooked because of significant diagnostic challenges. The combination of hemodynamic compromise and transesophageal echocardiography (TEE) findings allows for correct diagnosis. A large variety of putative risk factors for ICT and PE have been suggested, but these events are considered to be multifactorial. There are different proposed treatment modalities for these devastating complications. Unfortunately, in spite of growing knowledge in this area, intraoperative and postoperative mortalities remain very high. The retrospective nature of the study of these events makes the case reports extremely valuable.
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31
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Lee SH, Gwak MS, Choi SJ, Shin YH, Ko JS, Kim GS, Lee SY, Kim MH, Park HG, Lee SK, Jeon HJ. Intra-operative cardiac arrests during liver transplantation - a retrospective review of the first 15 yr in Asian population. Clin Transplant 2013; 27:E126-36. [DOI: 10.1111/ctr.12085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2012] [Indexed: 01/06/2023]
Affiliation(s)
- Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Soo Joo Choi
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Young Hee Shin
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Suk Young Lee
- Department of Anesthesiology and Pain Medicine; Jukjeon Dental Hospital; Republic of Korea
| | - Myung Hee Kim
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Hui Gyeong Park
- Department of Anesthesiology and Pain Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Suk-Koo Lee
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Republic of Korea
| | - Hee Jung Jeon
- Department of Anesthesiology and Pain Medicine; Veterans Health Service Medical Center; Republic of Korea
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32
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Aufhauser DD, Rose T, Levine M, Barnett R, Ochroch EA, Aukburg S, Greenblatt E, Olthoff K, Shaked A, Abt P. Cardiac arrest associated with reperfusion of the liver during transplantation: incidence and proposal for a management algorithm. Clin Transplant 2012; 27:185-92. [DOI: 10.1111/ctr.12052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 11/30/2022]
Affiliation(s)
- David D. Aufhauser
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Tom Rose
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Matthew Levine
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Rebecca Barnett
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - E. Andrew Ochroch
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Stanley Aukburg
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Eric Greenblatt
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Kim Olthoff
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Abraham Shaked
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Peter Abt
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
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33
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Sakai T, Matsusaki T, Dai F, Tanaka KA, Donaldson JB, Hilmi IA, Wallis Marsh J, Planinsic RM, Humar A. Pulmonary thromboembolism during adult liver transplantation: incidence, clinical presentation, outcome, risk factors, and diagnostic predictors. Br J Anaesth 2011; 108:469-77. [PMID: 22174347 DOI: 10.1093/bja/aer392] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraoperative pulmonary thromboembolism (PTE) is an often overlooked cause of mortality during adult liver transplantation (LT) with diagnostic challenge. The goals of this study were to investigate the incidence, clinical presentation, and outcome of PTE and to identify risk factors or diagnostic predictors for PTE. METHODS Four hundred and ninety-five consecutive, isolated, deceased donor LTs performed in an institution for a 3 yr period (2004-6) were analysed. The standard technique was a piggyback method with veno-venous bypass without prophylactic anti-fibrinolytics. The clinical diagnosis of PTE was made with (i) acute cor pulmonale, and (ii) identification of blood clots in the pulmonary artery or observation of acute right heart pressure overload with or without intracardiac clots with transoesophageal echocardiography. RESULTS The incidence of PTE was 4.0% (20 cases); cardiac arrest preceded the diagnosis of PTE [75% (15)] and PTE occurred during the neo-hepatic phase [85% (17)], especially within 30 min after graft reperfusion [70% (14)]. Operative and 60 day mortalities of patients with PTE were higher (P<0.001) than those without PTE (30% vs 0.8% and 45% vs 6.5%). Comparison of perioperative data between the PTE group (n=20) and the non-PTE group (n=475) revealed cardiac arrest and flat-line thromboelastography in three channels (natural, amicar, and protamine) at 5 min after graft reperfusion as the most significant risk factors or diagnostic predictors for PTE with an odds ratio of 154.32 [95% confidence interval (CI): 44.82-531.4] and 49.44 (CI: 15.6-156.57), respectively. CONCLUSIONS These findings confirmed clinical significance of PTE during adult LT and suggested the possibility of predicting this devastating complication.
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Affiliation(s)
- T Sakai
- Department of Anesthesiology, University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Yerlioglu E, Krishnamoorthy V, Jeon H, Gustin A, Nicolau-Raducu R. Patent foramen ovale and intracardiac thrombus identified by transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 2011; 26:1069-73. [PMID: 21757375 DOI: 10.1053/j.jvca.2011.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Indexed: 12/17/2022]
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Abstract
Hyperfibrinolysis, a known complication of liver surgery and orthotopic liver transplantation (OLT), plays a significant role in blood loss. This fact justifies the use of antifibrinolytic drugs during these procedures. Two groups of drug namely lysine analogues [epsilon aminocaproic acid (EACA) and tranexamic acid (TA)] and serine-protease-inhibitors (aprotinin) are frequently used for this purpose. But uniform data or guidelines on the type of antifibrinolytic drugs to be used, their indications and correct dose, is still insufficient. Antifibrinolytics behave like a double-edged sword. On one hand, there are benefits of less transfusion requirements but on the other hand there is potential complication like thromboembolism, which has been reported in several studies. We performed a systematic search in PubMed and Cochrane Library, and we included studies wherein antifibrinolytic drugs (EACA, TA, or aprotinin) were compared with each other or with controls/placebo. We analysed factors like intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality. Among the three drugs, EACA is least studied. Use of extensively studied drug like aprotinin has been restricted because of its side effects. Haemostatic effect of aprotinin and tranexamic acid has been comparable. However, proper patient selection and individualized treatment for each of them is required. Purpose of this review is to study various clinical trials on antifibrinolytic drugs and address the related issues like benefits claimed and associated potential complications.
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Affiliation(s)
- Jalpa Makwana
- Department of Anaesthesia, Jaslok Hospital and Research Centre, Mumbai, India
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Anesthesia care for liver transplantation. Transplant Rev (Orlando) 2011; 25:36-43. [PMID: 21126662 DOI: 10.1016/j.trre.2010.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 10/04/2010] [Indexed: 12/13/2022]
Abstract
Intraoperative transfusion practices for liver transplantation have evolved dramatically since the first transplants of the 1960s. It is important for today's clinicians to be current in their understanding of how transplant patients should be managed with regard to their coagulation profile, volume status, and general hemodynamic state. The anesthesia team is presented with the unique task of manipulating this tenuous balance in a rapid and precise manner when managing patients undergoing liver transplantation. Although significant progress has been made in reducing blood product administration, it is still common to encounter large volume blood loss in these cases. Increasingly, clinicians are challenged to justify transfusion practices with a stronger evidentiary base. The current state of the literature for transfusion guidelines and blood product management in this particular patient subset will be discussed, as well as a variety of means (both pharmacologic and otherwise) used to reduce the need for transfusion. The aim was to review the latest evidence on these topics, as well as to highlight areas that need further clarification regarding their role in the optimal care of these patients.
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Boone JD, Sherwani SS, Herborn JC, Patel KM, De Wolf AM. The Successful Use of Low-Dose Recombinant Tissue Plasminogen Activator for Treatment of Intracardiac/Pulmonary Thrombosis During Liver Transplantation. Anesth Analg 2011; 112:319-21. [DOI: 10.1213/ane.0b013e31820472d4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Xia VW, Ho JK, Nourmand H, Wray C, Busuttil RW, Steadman RH. Incidental intracardiac thromboemboli during liver transplantation: incidence, risk factors, and management. Liver Transpl 2010; 16:1421-7. [PMID: 21117252 DOI: 10.1002/lt.22182] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Even though numerous cases of massive thromboemboli have been reported in the literature, intracardiac thromboemboli (ICTs) incidentally found during orthotopic liver transplantation (OLT) have not been examined. In this study, we retrospectively examined the incidence, risk factors, and management of incidental ICTs during OLT. After institutional review board approval, adult patients who underwent OLT between January 2004 and December 2008 at our center were reviewed. ICTs were identified and confirmed by the examination of OLT datasheets, anesthesia records, and recorded transesophageal echocardiography (TEE) clips. The clinical presentation, management, and outcomes of the patients with ICTs were reviewed. Risk factors were analyzed by multivariate logistic regression. During the study period, 426 of the 936 adult OLT patients (45.5%) underwent intraoperative TEE monitoring. Incidental ICTs were identified in 8 of these 426 patients (1.9%). Two ICTs occurred before reperfusion, and 6 ICTs occurred after reperfusion. The treatment was at the discretion of the treating physicians; however, none of the patients received an anticoagulant or thrombolytics. Multivariate analysis identified 2 independent risk factors for intraoperative incidental ICTs: the presence of symptomatic or surgically treated portal hypertension (a history of gastrointestinal bleeding, a transjugular intrahepatic portosystemic shunt procedure, or portocaval shunt surgery) before OLT and intraoperative hemodialysis (odds ratios of 4.05 and 7.29, respectively; P < 0.05 for both). In conclusion, incidental ICTs during OLT occurred at a rate of 1.9% and were associated with several preoperative and intraoperative risk factors. The use of TEE allows early identification, which may be important. Our management for incidental ICTs is described; however, no conclusions can be made about the optimal therapy.
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Affiliation(s)
- Victor W Xia
- Department of Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095-7430, USA.
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Cherian TP, Chiu K, Gunson B, Bramhall SR, Mayer D, Mirza DF, Buckels JAC. Pulmonary thromboembolism in liver transplantation: a retrospective review of the first 25 years. Transpl Int 2010; 23:1113-9. [PMID: 20497402 DOI: 10.1111/j.1432-2277.2010.01105.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The evidence on the state of 'haemostasis' at the time of liver transplantation (LT) is conflicting, with recent publications that suggest a hypercoagulable state, in contrast to traditionally held views. These findings raise the issue of thrombo-embolic complications after LT, an area of interest which has received little attention in recent published literature. We therefore conducted a retrospective review of our experience of 3000 liver transplants over 25 years. Our prospective transplant database was reviewed to find all patients who were suspected to have had a pulmonary embolism (PE) during or following LT. Paediatric transplants were excluded. A part of this database was cross referenced against hospital records to corroborate its accuracy. Clinical records of all these patients were reviewed and relevant aspects collated and analyzed. Following exclusion of the paediatric recipients, 2 149 adults were reviewed to find 36 patients in whom a PE was suspected (median age 49), 21 of whom were within 90 days of transplant (median duration 22 days). PE was ruled out in 10, unconfirmed in two, confirmed in eight patients; and in one, air embolism was found. All PEs occurred in hospital, but aetiology of liver failure was varied. Of note, two patients died of an on-table PE and one patient of chronic rejection/disease recurrence (Primary Sclerosing Cholangitis). The remaining five are still alive (median survival of 65 months). Although thromboprophylaxis is now routine in our unit, its use in these patients could not be confirmed from records available. Fifteen PE were suspected and confirmed after 90 days from transplant (six within, and nine out with the first year). Acute PE in the setting of LT has an incidence rate in our series of 0.37% that would appear to be lower than previously reported and lower than one would expect after a 'major complex' category operation. This potentially suggests that the overall haemostatic function in these patients is still weighted towards hypocoagulation with the resultant risk of excessive bleeding. Aetiology of liver disease did not seem to confer a higher risk in our series. The prognosis after post-operative PE appears good although sudden death due to an on-table embolism is a rare but significant risk.
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El-Baghdadi MM, Sakai T. Fatal Pulmonary Embolism During Liver Transplantation in a Patient With Fulminant Hepatic Failure: A Diagnostic Challenge of the “Flat-Line” Thromboelastogram. J Cardiothorac Vasc Anesth 2010; 24:641-3. [DOI: 10.1053/j.jvca.2009.07.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2009] [Indexed: 11/11/2022]
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Mejia A, Mendoza ML, Kieta D, Gulden H, Aramoonie AE, Lee GW, Cheng S. Nonfatal Intracardiac Thromboembolism During Liver Transplantation. J Cardiothorac Vasc Anesth 2010; 24:109-11. [DOI: 10.1053/j.jvca.2009.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Indexed: 11/11/2022]
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Warnaar N, Molenaar IQ, Colquhoun SD, Slooff MJH, Sherwani S, de Wolf AM, Porte RJ. Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review. J Thromb Haemost 2008; 6:297-302. [PMID: 18005235 DOI: 10.1111/j.1538-7836.2008.02831.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). METHODS We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. RESULTS Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. CONCLUSION Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P < 0.001). Intraoperative PE and ICT during OLT appear to have multiple etiologies and may occur unexpectedly at any time during the procedure.
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Affiliation(s)
- N Warnaar
- Section Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJH, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant 2007; 7:185-94. [PMID: 17227567 DOI: 10.1111/j.1600-6143.2006.01591.x] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although several randomized controlled trials (RCTs) have shown the efficacy of antifibrinolytic drugs in liver transplantation, their use remains debated due to concern for thromboembolic complications. None of the reported RCTs has shown a higher incidence of these complications in treated patients; however, none of the individual studies has been large enough to elucidate this issue completely. We therefore performed a systematic review and meta-analysis of efficacy and safety endpoints in all published controlled clinical trials on the use of antifibrinolytic drugs in liver transplantation. Studies were included if antifibrinolytic drugs (epsilon-aminocaproic acid, tranexamic acid (TA) or aprotinin) were compared with each other or with controls/placebo. Intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality were analyzed. We identified 23 studies with a total of 1407 patients which met the inclusion criteria. Aprotinin and TA both reduced transfusion requirements compared with controls. No increased risk for hepatic artery thrombosis, venous thromboembolic events or perioperative mortality was observed for any of the investigated drugs. This systematic review and meta-analysis does not provide evidence for an increased risk of thromboembolic events associated with antifibrinolytic drugs in liver transplantation.
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Affiliation(s)
- I Q Molenaar
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lerner AB. Pro: Antifibrinolytics are safe and effective in patients undergoing liver transplantation. J Cardiothorac Vasc Anesth 2006; 20:888-90. [PMID: 17138101 DOI: 10.1053/j.jvca.2006.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Adam B Lerner
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Hudcova J, Schumann R. Fatal Right Ventricular Failure with Intracardiac Thrombus Formation During Liver Transplantation Not Apparent on Postmortem Examination. Anesth Analg 2006; 103:506. [PMID: 16861462 DOI: 10.1213/01.ane.0000227210.74477.a9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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