Case report
Intracardiac tromboembolism during liver transplantation
Tromboembolismo intracardíaco durante trasplante hepático
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(A) frontal view, (B) lateral view (reproduced with permission from Nicholas Chrimes).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Charco-Mora, R. Urtubia, L. Reviriego-Agudo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Charco-Mora" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Urtubia" ] 2 => array:2 [ "nombre" => "L." 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Longo, M. Palacios, M.E. Tinti, J. Siri, J.I. de Brahi, M.C. Cabrera Shulmeyer" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Longo" "email" => array:1 [ 0 => "silvinalongo@icloud.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Palacios" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.E." "apellidos" => "Tinti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Siri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J.I." "apellidos" => "de Brahi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "M.C." "apellidos" => "Cabrera Shulmeyer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Privado Universitario de Córdoba, Córdoba, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Privado Universitario de Córdoba, Córdoba, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología, Universidad de Valparaíso, Valparaíso, Chile" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tromboembolismo intracardíaco durante trasplante hepático" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1194 "Ancho" => 1583 "Tamanyo" => 140907 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Four chamber view showing a thrombus in the left atrium and another one transiting from the right atrium through the patent foramen ovale. Note the enlargement of the right-sided cavities. RA: right atrium; LA: left atrium; RV: right ventricle; LV: left ventricle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac embolism and intracardiac thrombi (ICT) are complications of liver transplantation (LT). They may occur during reperfusion of the organ, and are associated with a high rate of morbidity and mortality.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There is currently no standard treatment for ICT, but the diagnostic technique of choice is transoesophageal echocardiography (TOE) monitoring. TOE enables the anaesthesiologist to rule out differential diagnoses, including hypovolaemia and myocardial ischaemia, during the acute phases of transplantation, and it should be used all liver transplant patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 43-year-old man with terminal liver disease measured on the model for end-stage liver disease (MELD) scale, cirrhosis due to haemochromatosis, and portal vein thrombosis diagnosed preoperatively by 3D computed tomography, together with grade <span class="elsevierStyleSmallCaps">1</span> portal vein thrombosis (less than 50% obstruction, according to the Yerdel and McMaster classification).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A few weeks prior to transplantation, the patient was hospitalised for episodes of abdominal infection and acute kidney failure secondary to hepatorenal syndrome, without the need for haemodialysis. He also presented grade <span class="elsevierStyleSmallCaps">1</span> hepatic encephalopathy and hepatopulmonary syndrome with right pleural effusion, which was drained the day before surgery.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although analytical tests had shown no significant metabolic alterations, during surgery the patient presented acute haemodynamic decompensation after declamping, with severe hypotension and extreme bradycardia. Advanced cardiopulmonary resuscitation manoeuvres were started, and adrenaline followed by isoproterenol were administered, after which nodal rhythm was recovered. However, due to the persistence of bradycardia, a transient percutaneous pacemaker was placed through a Swan-Ganz introducer. Given the acute and unexpected nature of the event, the anaesthesiologist requested placement of a diagnostic TOE probe, which showed massive intracardiac thrombosis. Annex, video 1, shows a thrombus from the inferior vena cava located in the right atrium, together with a pacemaker cable.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, and Annex, video 2 show a thrombus passing through the foramen ovale of the interatrial septum and thrombosis in the left atrium.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Annex, video 3, shows a thrombus at the level of the mitral valve ready to migrate to the left ventricle.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite our resuscitation attempts, the patient deteriorated rapidly and died. TOE monitoring was fundamental in the diagnosis and management of this severe complication.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Reperfusion is one of the most critical moments during LT surgery, and is a risk factor for mortality.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> The triad of reperfusion hypotension secondary to the release of blood from the hypothermic organ, which causes acidosis and hyperkalaemia induced by the preservation solution, end-stage liver disease-induced coagulation disorders, and the presence of a pulmonary artery catheter as a source of clot formation,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> favour the formation of ICT at the time of reperfusion.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The cause of ICT in our patient may have been multifactorial. He was hospitalised for infectious symptoms weeks before the transplant, and multiple blood products were administered prior to organ reperfusion. He presented partial portal thrombosis, which was resolved with simple surgical thrombectomy. This procedure has been associated with a higher risk of bleeding, which in turn increases the complexity of the transplant and the risk of morbidity and mortality. Another cause could be rethrombosis. Although the cause of this is unclear, some have suggested it could be due to intimal damage caused during thrombectomy.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Coagulation in patients with end-stage liver disease (ELD) is extremely deficient due alterations in the delicate balance between procoagulants, anticoagulants and fibrinolytic proteins in the diseased liver. Based on this, we believe that it would have been very useful to use TOE monitoring from the beginning of surgery for early detection of thrombosis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">During LT surgery, the pulmonary artery is catheterised in order to monitor cardiac output using volumetric measuring devices (PiCCO/EV-1000). The appearance of ICT is heralded by sudden haemodynamic changes, hypoxia, increased central venous pressure, and an increase or decrease in pulmonary and arterial pressures; however, the most accurate, real-time diagnosis of ICT is achieved with TOE.</p><p id="par0065" class="elsevierStylePara elsevierViewall">ICTs, though considered rare or possibly “underdiagnosed,” are a life-threatening complication. TOE is not routinely used in Latin America in transplant surgery, although it is currently considered an essential monitoring tool, with a sensitivity of 80% and a specificity of 100% for the diagnosis of thrombi.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The echocardiographic images obtained show the mechanism by which the thrombus reaches the left side of the heart. The normal pressure of the left atrium is 12–15<span class="elsevierStyleHsp" style=""></span>mmHg, and that of the right atrium ranges from 0 to 5<span class="elsevierStyleHsp" style=""></span>mmHg. When the pressure of the right atrium increases due to thrombosis, as in this case, and exceeds the pressure on the left side, the thrombi pass into the systemic circulation if the foramen ovale is open, which is the case in between 25% and 30% of adult patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Once ICT is detected, the treatment focuses primarily on intensifying cardiovascular support with inotropic and vasoactive agents to maintain adequate blood pressure. After this, the transplant team will discuss whether intravenous heparin should be administered to prevent further growth of the clot,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> or whether tissue plasminogen activator (tPA) is more appropriate, as recommended by some authors<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> to temporarily relieve the pressure caused by the clot in the cardiovascular system. This approach is still controversial due to the risk of major intraoperative haemorrhage caused by administration of a thrombolytic agent.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In these cases, TOE plays a major role, not only in confirming diagnosis, but also in monitoring resolution of the thrombi in response to treatment.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Although it is an invasive procedure, studies have shown TOE to be safe and effective in patients with ELD and oesophageal varices, and complications directly associated with insertion and manipulation of the probe are uncommon.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2003, the ACC/AHA/ASE guidelines for the clinical application of echocardiography were updated,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> and in 2010, the ASA/SCA guidelines for perioperative TOE<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> recommended this technique in surgeries associated with major changes in volume and significant haemodynamic compromise. This would include LT.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Patients undergoing LT are particularly vulnerable to secondary hypotension due to failure or dysfunction of the right ventricle and changes in pulmonary artery pressure; therefore, TOE is an important monitoring tool during LT.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> TOE also helps identify cases of dynamic left ventricular outflow tract obstruction,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> and improves volaemia and myocardial function monitoring</p><p id="par0100" class="elsevierStylePara elsevierViewall">Since the best treatment is prevention, identifying risk factors and the patients most likely to present ICT, and using TOE from the start of surgery will help prevent, identify and treat the formation of ICT during LT.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Transplant surgery teams should consider all ELD patient with predictive factors for ICT (such as venous thrombosis, preoperative haemodialysis, history of surgery for gastrointestinal haemorrhages or thrombophilia) as being at high risk for thrombosis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Portal vein thrombosis, which occurs in between 1% and 16% patients with cirrhosis, is a complication of ELD.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> This creates technical difficulties during LT, which is why these patients should be treated by expert surgical teams with experience in re-establishing adequate portal flow to the new graft. Portal vein thrombosis is a risk factor for intra- and postoperative complications, but it can be treated before or during transplant.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In order to restore haemodynamic stability during reperfusion, ICTs should be managed with inotropic support, suspension of antifibrinolytics (if started) and low-dose heparin, with thrombolytic therapy under direct TOE vision being reserved for refractory thrombi. The intraoperative TOE monitoring plays a vital role in the diagnosis of the different pathologies that can occur during LT, and can help the anaesthesiologist choose the right treatment in the case of unanticipated intraoperative haemodynamic compromise.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Placing a TOE probe at the start of surgery could have changed the outcome in our patient by facilitating early diagnosis of thrombosis, an event that may be underdiagnosed, and allowing us to administer prompt treatment to avoid massive thrombosis and death. Without the routine use of TOE during LT, the incidence of ICT will remain an unrecognised event.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1065099" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1013113" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1065098" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1013112" "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" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-02" "fechaAceptado" => "2018-01-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1013113" "palabras" => array:3 [ 0 => "Intraoperative transesophageal echocardiography" 1 => "Thrombosis" 2 => "Liver transplantation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1013112" "palabras" => array:3 [ 0 => "Ecocardiografía transesofágica intraoperatoria" 1 => "Trombosis" 2 => "Trasplante hepático" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a case of intraoperative cardiac trombosis during orthotopic liver transplant surgery that resulted in intraoperative death. By using transoesophageal echocardiography, the cause of the decompensation of the patient could be determined and the mechanism of trombus migration from thrombi from the venous circulation to the left heart was accurately observed.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos un caso de trombosis cardíaca intraoperatoria durante una cirugía de trasplante ortotópico hepático que derivó en muerte intraoperatoria. Mediante ecocardiografía transesofágica, colocada durante la descompensación del paciente, se pudo determinar la causa del problema y observar con precisión el mecanismo de migración de trombos desde la circulación venosa hacia el corazón izquierdo.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Longo S, Palacios M, Tinti ME, Siri J, de Brahi JI, Cabrera Shulmeyer MC. Tromboembolismo intracardíaco durante trasplante hepático. Rev Esp Anestesiol Reanim. 2018;93:394–397.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1194 "Ancho" => 1583 "Tamanyo" => 140907 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Four chamber view showing a thrombus in the left atrium and another one transiting from the right atrium through the patent foramen ovale. Note the enlargement of the right-sided cavities. RA: right atrium; LA: left atrium; RV: right ventricle; LV: left ventricle.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pptx" "ficheroTamanyo" => 18620436 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management and outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.A. Yerdel" 1 => "B. Gunson" 2 => "D. Mirza" 3 => "K. Karayalcin" 4 => "S. Olliff" 5 => "J. 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