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Metaanálisis y revisión sistemática" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 535 "Ancho" => 2508 "Tamanyo" => 185593 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Time (in minutes) to first request analgesia.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.U. Huda, M.Z. Mughal" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A.U." "apellidos" => "Huda" ] 1 => array:2 [ "nombre" => "M.Z." 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "260" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Perez-Ajami, P. Carmona García, I. Zarragoikoetxea Jauregui, G. Sales Badía, P. Argente Navarro" "autores" => array:5 [ 0 => array:3 [ "nombre" => "D." "apellidos" => "Perez-Ajami" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Carmona García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Zarragoikoetxea Jauregui" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Sales Badía" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:4 [ "nombre" => "P." "apellidos" => "Argente Navarro" "email" => array:1 [ 0 => "argente_marnav@gva.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Anesthesiology and Critical Care, Hospital La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiothoracic Anesthesiology, Hospital Universitari I Politècnic La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Thoracic Surgery, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Anesthesiology and Critical Care, Hospital Universitari I Politècnic La Fe, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombo en tránsito izquierdo intraoperatorio en trasplante bipulmonar diagnosticado por ecocardiografía transesofágica: ¿qué es lo siguiente?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 523 "Ancho" => 755 "Tamanyo" => 39365 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">40º Midoesophageal plane showing the thrombus in the LUPV (left upper pulmonary vein).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lung transplantation is an established treatment for patients with end-stage chronic respiratory failure. Intraoperative pulmonary vein thrombosis (PVT), vascular kinking or stenosis, and clots in the left atrium (LA) are known but rare and challenging diagnoses.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Turbulent flow on colour doppler and high velocity on pulse wave doppler in the left and right pulmonary vein anastomosis are the main echocardiographic findings.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, evidence of free-floating, potentially embolizing clots visible in 2D in the intraoperative period is unusual.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Though uncommon, PVT and left atrium thrombus have potentially serious, life-threatening consequences, such as allograft failure, stroke, pulmonary oedema, and sudden death.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In order to prevent these complications, donor systemic heparinization, administration of prostaglandin E1 (Perfadex®) solution to preserve the donor lung, flushing, and retrograde graft reperfusion are routinely performed.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 61-year-old man who underwent sequential double lung transplantation due to terminal stage COPD. The surgical procedure was performed through a clamshell incision without extracorporeal membrane oxygenation (ECMO), and the donor’s lung was obtained by controlled donation after circulatory death under systemic heparinization with 500 IU/kg. After both lungs were implanted and reperfused, a full protocolized transoesophageal echocardiography (TOE) study was performed, focusing on the flow in left and right pulmonary venous anastomosis. In a modified mid-oesophageal two chamber view, a large, de novo, heterogenous, dense, hyperechoic mobile mass was identified (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) in the left atrium emerging from the left upper pulmonary vein anastomosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The echocardiographic characteristics, size, and location of the mass (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) were consistent with a venous clot in transit, and the surgical team was notified. The anastomosis was then reopened and a 2 cm fresh clot was extracted.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first report in the literature in which TOE enabled diagnosis of a venous clot in transit after double lung transplantation and guided immediate intraoperative treatment. This is a potentially fatal complication in the early postoperative period after lung transplantation due to the risk of systemic embolization and stroke. Pulmonary grafts from controlled donation after circulatory death and recipients supported by preoperative ECMO are prognostic factors for thrombosis,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> but in this case controlled donation after circulatory death was the only prothrombotic risk factor in both the donor and recipient. The recipient reported no personal or family history of thrombosis, although patients on the transplant waiting list in our hospital are not routinely screened for thrombophilia. The surgeons performed all the protocolized steps to prevent clotting and flushed the graft before implantation; they observed no signs of thrombus. According to some reports, if full anticoagulation and cardiac bypass are not used during sequential double lung transplantation, the pulmonary vasculature and anastomoses are exposed to longer periods of surgical manipulation, and this can promote clot formation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Perioperative pulmonary venous thrombosis (PVT) has rarely been described in the literature. The incidence and management of this complication is unclear, but according to some studies, up to 15% of lung transplant patients present PVT.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Intraoperative TOE is recommended to rule out the presence of patent foramen ovale (PFO) or atrial septal defect, because a previously left-to-right interatrial shunt can be reversed during lung transplant due to elevated right-sided pressures, and this could lead to paradoxical embolism and stroke.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> TOE is also used to monitor suture complications.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> A complete echocardiography study that includes blood flow measurement in the anastomosis with spectral doppler at the end of the surgery is paramount. Velocities over 120 cm/s suggest PVT or significant pulmonary vein obstruction (kinking, mismatch, etc.) and the sutures must be reviewed.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> In the postoperative setting, pulmonary vascular complications should be suspected when hypoxemia, pulmonary hypertension and oedema occur. Primary graft dysfunction, infection, acute rejection, and myocardial dysfunction are included in the differential diagnosis. In addition to a CT scan, the use of bedside TOE in the intensive care unit (ICU) may also help diagnose this complication in the immediate postoperative period, and can be used to follow up thrombosis regression during anticoagulation therapy.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">PVT treatment remains controversial, and depends on several factors such as the setting (intraoperative, postoperative), thrombus size, degree of obstruction, and clinical course. A more conservative approach with adequate anticoagulation has been advised in the case of a small non-obstructive postoperative thrombus with minimal acceleration of blood flow at the site of the thrombus. Although poor outcomes have been reported, emergency thrombectomy has also been described when a large postoperative thrombus is detected,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> although postoperative PVT is not always treated surgically as it carries a high risk of bleeding in a patient with a closed chest who may even be extubated.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Intraoperative management of a clot in transit differs from postoperative management because the clot poses a high risk of embolism and can be removed by reopening the anastomosis. Though challenging, aspiration of a visible, free-floating mass in the left side of the heart should be first choice rather than just intraoperative anticoagulation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Both intraoperative and postoperative anticoagulation therapy should be considered, taking into account both bleeding risk and clinical status. Further evidence is needed before a particular type and duration of anticoagulation can be recommended to treat a thrombus, but no differences have been reported with vitamin K antagonist oral anticoagulants or heparin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Follow-up TOE to assess clot re-formation after discharge home will not be required if successful removal of the clot has been confirmed by imaging tests, and there is no evidence of thrombophilia and no new symptoms of pulmonary vein blood flow obstruction.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, intraoperative TOE is recommended in the management of patients undergoing lung transplantation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It plays a key role in the diagnosis of intracardiac thrombus by assessing blood flow in the pulmonary vein anastomosis during sequential double lung transplantation, and can help guide decision-making and treatment. Removal of clots in transit, whenever feasible, should be the first line treatment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">On behalf of all authors, the corresponding author states that there are no conflicts of interest and there are no relevant sources of funding for this manuscript.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Consent for publication</span><p id="par0065" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of this case report and any accompanying images.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2165857" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1836886" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2165856" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1836887" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Consent for publication" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-12-04" "fechaAceptado" => "2023-03-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1836886" "palabras" => array:4 [ 0 => "Pulmonary vein thrombosis" 1 => "Double lung transplantation" 2 => "Transoesophageal echocardiography" 3 => "Clot in transit" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1836887" "palabras" => array:4 [ 0 => "Trombosis de la vena pulmonar" 1 => "Trasplante bipulmonar" 2 => "Ecocardiografía transesofágica" 3 => "Trombo en tránsito" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 61-year-old man with no predisposition to thrombosis underwent sequential double lung transplantation without extracorporeal membrane oxygenation (ECMO) support due to terminal stage COPD. After implantation and reperfusion of both lungs, a complete transoesophageal echocardiography study was performed to check the pulmonary venous anastomosis. The study showed a large, heterogeneous, dense, hyperechoic free-floating mass in the left atrium compatible with a clot in transit from the pulmonary circulation. The surgical team were notified of this finding so that they could reopen the anastomosis and remove the clot to prevent a major complication. There were no clinical manifestations when the patient was awakened.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Un varón de 61 años sin predisposición trombótica es sometido a trasplante bipulmonar como último tratamiento para su EPOC terminal sin soporte de ECMO. Tras el implante y la reperfusión de ambos pulmones, se realizó un examen ecocardiográfico transesofágico completo para comprobar principalmente las anastomosis de las venas pulmonares. En este estudio se identificó una gran masa móvil, hiperecogénica, densa y heterogénea en la aurícula izquierda, compatible con un trombo en tránsito desde la circulación venosa pulmonar. Este hallazgo fue comunicado al equipo quirúrgico inmediatamente para reabrir la anastomosis y retirar el coágulo antes de mayores consecuencias. No hubo manifestaciones clínicas cuando se despertó al paciente.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 560 "Ancho" => 755 "Tamanyo" => 35241 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">80–100º Midoesophageal plane showing thrombus (T) in LA (left atrium).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 523 "Ancho" => 755 "Tamanyo" => 39365 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">40º Midoesophageal plane showing the thrombus in the LUPV (left upper pulmonary vein).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Four-year prospective study of pulmonary venous thrombosis after lung transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.L. 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