Risk factors and outcomes of intracardiac thrombosis during orthotopic liver transplantation.
Al-Darzi W, El-Atrache M, Georgie F, Sadiq O, Singla S, Fernandez C, Pompa R, Galusca D, Yoshida A, and Jafri SM. Risk factors and outcomes of intracardiac thrombosis during orthotopic liver transplantation. Am J Transplant 2017; 17:582.
Am J Transplant
Introduction: Intracardiac Thrombosis (ICT) during Orthotopic Liver Transplantation (OLT) is an uncommon event associated with high mortality. The incidence of ICT during OLT is estimated at 1.2 to 6.2% with intraoperative mortality up to 82%. We aimed to evaluate risk factors associated with and outcomes related to ICT during OLT. Methods: A retrospective data of 388 patients underwent liver transplantation at an urban transplant center from January 2013 to October 2016. Comprehensive demographic, clinical, laboratory, and intraoperative data were obtained. Results: Six patients were found to have documented ICT during OLT; 4 cases were recognized during the reperfusion stage, and 1 occurred during pre-anhepatic. Preoperative thrombocytopenia (platelets count <150 X 109/L) was present in 4 patients. 2 patients had portal vein thrombosis. 3 patients had acute kidney injury, but no intraoperative hemodialysis was performed, Aminocaproic acid was used in 5 patients, and 3 patients were given protamine. None had prior history of atrial fibrillation, Trans-jugular intrahepatic portosystemic shunt, or history of gastrointestinal bleeding. Systemic hypotension (n=5), elevated pulmonary arterial pressure (n=1), or loss of pulses (n=2) were clinical manifestations noted. Transesophageal Echocardiographic findings included elevated pulmonary artery pressure (1/6), right ventricular strain (1/6), pulmonary artery thrombus (1/6), and ICT in all six patients (4/6 had right sided thrombus). 5 patients had cardiac arrest, of those 3 patients expired intraoperatively. One patient was re-transplanted due hepatic artery thrombosis with extensive hepatic necrosis. Treatment modalities used included: Tissue plasminogen activator therapy (TPA) alone was given to 1 patient who did not survive, heparin only to 1 patient with resolution, and combination of both was used in 2 patients with clot resolution achieved. Two patients did not receive either therapy and expired. Conclusion: Cardiac thrombosis should always be considered in any patient having hemodynamic compromise during liver transplant surgery. Preoperative demographic, clinical, laboratory and historical risk factors did not differ in the patients with thrombosis. Transesophageal Echocardiography is a useful diagnostic tool in identifying these thrombi. Treatment of ICT is challenging, however using both TPA and heparin could achieve better outcomes.