Uh Oh…Is That Supposed To Be There???

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 hepatopulmonary 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

Learning Objectives:

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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  1. Tiukinhoy-Liang SD, Rossi JS, Bayram M, De Luca L, Gafoor S, Blei A, Flamm S, Davidson CJ, Gheorghiade M. Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation. Am J Cardiol 2006;98:178-81
  2. Mejia A, Mendoza ML, Kieta D, Guiden H, Aramoonie AES, Lee GW, Cheng S. Nonfatal intracardiac thromboembolism during liver transplantation. J Cardiothorac Vasc Anesth 2010;24:109-11
  3. Cotton CL, Gandhi S, Vaitkus PT, Massad MG, Benedetti E, Mrtek RG, Wiley TE. Role of echocardiography in detecting portopulmonary hypertension in liver transplant candidates. Liver Transpl 2002;8:1051-4
  4. Ellis JE, Lichtor JL, Feinstein SB, Chung MR, Polk SL, Broelsch C, Emond J, Thislethwaite JR, Roizen MF. Right heart dysfunction, pulmonary embolism, and paradoxical embolization during liver transplantation. Anesth Analg 1989;68:777-82
  5. Ellenberger C, Mentha G, Giostra E, Licker M. Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation. J Clin Anesth 2006;18:367-71
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  7. 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;16:1421-27
  8. O’Connor CJ, Roozeboom D, Brown R, Tuman KJ. Pulmonary thromboembolism during liver transplantation: possible association and antifibrinolytic drugs and novel treatment options.  Anesth Analg 2000;91:296-9
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  10. Gologorsky E, De Wolf AM, Scott V, Aggarwal S, Dishart M, Kang Y. Intracardiac thrombus formation and pulmonary thromboembolism immediately after graft reperfusion in 7 patients undergoing liver transplantation. Liver Transpl 2001;7:783-89
  11. De Wolf AM, Begliomini B, Gasior TA, Kang Y, Pinsky MR. Right ventricular function during orthotopic liver transplantation. Anesth Analg 1993;76:562-8
  12. Krowka MJ, Plevak DJ, Findlay JY, Rosen CB, Wiesner RH, Krom RAF. Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. Liver Transpl 2000;6:443-50
  13. Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y. Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation.  Liver Transpl Surg 1996;2:426-30
  14. Krowka MJ, Mandell MS, Ramsay AE, Kawut SM, Fallon MB, Manzarbeita C, Pardo Jo M, Marotta P, Uemoto S, Stoffel MP, Benson JT. Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl 2004;10:174-82
  15. Starkel P, Vera A, Gunson B, Mutimer D. Outcome of liver transplantation for patients with pulmonary hypertension. Liver Transpl 2002;8:382-88
  16. Hofer CK, Zollinger A, Rak M, Matter-Ensner S, Klaghofer R, Pasch T, Zalunardo MP.  Therapeutic impact of intra-operative transesophageal echocardiography during noncardic surgery. Anaesthesia 2004;59:3-9

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