By: SK Shillcutt, MD, FASE
The use of transesophageal echocardiography (TEE) in liver transplantation is often used to manage hemodynamics, measure pulmonary artery pressures, and guide therapeutic interventions. After graft implantation, the caval clamps are removed, and is often a time of significant cardiopulmonary changes. Anesthesiologist can use TEE to watch for right ventricular failure, a common cause of hypotension and arrhythmias after unclamping. TEE can be used to identify proper filling, right ventricular distention, right ventricular function, tricuspid regurgitation and right-sided cardiac outputs.
With improvements in survival of post liver transplantation, older patients have become eligible for transplantation.1 These patients often have higher prevalence of coronary artery disease and other coronary risk factors. Recent studies show that echocardiography perioperatively reduces incidence of cardiac and pulmonary events. Cotton, et al uses positive predictive value to show that echocardiography is a useful tool in estimating pulmonary artery systolic pressure in liver transplant patients as part of the preoperative evaluation.2 The use of transesophageal echocardiography (TEE) performed continuously through liver transplantation has shown to provide clarification the mechanism of myocardial dysfunction, visualize and lyse thrombous or embolisms, and asses ventricular function following transplantation.3-12
Common echocardiography findings after unclamping during liver transplantation associated with right ventricular failure are right ventricular dilation, right ventricular dysfunction, intraatrial septal bowing to the left, right to left shunting through a patent foramen ovale, worsening tricuspid regurgitation from baseline, pulmonary hypertension, microemboli consistent with air and/or debris, and acute thromboemboli.
The more recently reported phenomenon of intraoperative cardiopulmonary thromboembolism has been a major contributor to patients mortality and morbidity during and following liver transplantation.6,7 Although this is a rare event, it is often a lethal complication during orthotopic liver transplantation. Frequent clinical symptoms include systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse.8 Retrospective studies show a relationship between cardiopulmonary-related mortality and initial (untreated) pre-orthotopic liver transplantation pulmonary hemodynamics.13 Additional pulmonary complications that arise from liver transplantation include heptaopulmonary syndromes and portopulmonary hypertension and generally believed to adversely affect outcome after liver transplantation. Echocardiography is able to detect severe pulmonary hypertension syndrome, and information can be used to diagnose, treat and follow critical cardiac events during the intraoperative period.14,15,16
1. Right heart failure is a complication of unclamping the vena cava during liver transplantation.
2. Causes of right heart failure during liver transplantation can be microemboli from air and debris, thromboembolus, acute or chronic (or both) pulmonary hypertension, severe tricuspid regurgitation, acute distension from volume overload, acidosis, hyperkalemia or ischemia (multiple factorial).
3. Transesophageal echocardiography (TEE) can rapidly identify thrombus, emboli, right ventricular function, triscuspid regurgitation, filling pressures, right sided cardiac output, as well as left-sided function and filling.
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