Do Not Touch the Heart ... Please

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Conference Proceeding

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Right atrial injury during liver transplant is very rare. We are presenting a case of polycystic kidney/liver disease admitted for combined liver and kidney transplant, complicated by right atrial tear during dissection phase. A 63-year-old man with a history of autosomal dominant polycystic kidney disease and significant liver involvement, presented for liver and kidney transplant. Baseline transesophageal echocardiographic (TEE) was remarkable for compression of the right side of the heart by a large cystic liver. It was initially planned to utilize a piggyback technique. The liver was mobilized from both the left and right side with electrocautery and ligation; thereafter, the hepatic artery, common bile duct and lymphatics were ligated and divided. The portal vein was then mobilized both proximally and distally and divided. Following a very difficult dissection of the liver, the surgeon noted that the diaphragm had been divided. Moreover, because of the enlarged recipient liver (14.8 Kg), dissection on the vena cava was very difficult. During this dissection, severe hypotension was encountered. The use of multiple vasopressors resulted in no improvement in the hemodynamic picture. Transesophageal echocardiographic images at the time demonstrated cardiac tamponade. A pericardial window was fashioned via the abdominal field, blood was drained, and hemodynamic stability was restored. Shortly thereafter, during mobilization of the native liver, the patient, again, became profoundly hypotensive and developed pulseless electrical activity (PEA). Advanced Cardiac Life Support (ACLS) protocol was initiated with return of spontaneous circulation within 2-3 minutes. It was noted that the inferior vena cava (IVC), at the junction with right atrium, had been injured during dissection and there was significant hemorrhage. . The tear was clamped and massive transfusion was initiated while the recipient liver was fully dissected and explanted. The donor liver was implanted using the classic caval technique. After reperfusion, the pericardial window was extended and more bleeding was detected. The right atrial tear was repaired and the bleeding was controlled; following this, the liver anastomoses were completed. Although the patient hemodynamic status had stabilized, the decision was made to delay the kidney transplant in order to allow for further resuscitation in the intensive care unit. The patient returned the following day for kidney transplant, which was uneventful.





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