Published online Oct 13, 2021. doi: 10.5313/wja.v10.i1.1
Peer-review started: June 7, 2021
First decision: July 27, 2021
Revised: August 10, 2021
Accepted: September 26, 2021
Article in press: September 26, 2021
Published online: October 13, 2021
Processing time: 127 Days and 13.3 Hours
The intraoperative management of patients undergoing orthotopic liver transplantation (OLT) frequently encounters hemodynamic instability after reperfusion of the new liver graft. The resulting post-reperfusion syndrome is characterized by an increase in pulmonary vascular resistance and decrease in systemic vascular resistance. In the presence of a left to right intracardiac shunt, this hemodynamic perturbance can lead to shunt reversal followed by hypoxemia and embolization of air and debris into the systemic circulatory system.
A 43 years-old male with end-stage liver disease due to primary sclerosing cholangitis complicated by portal hypertension and hepatocellular carcinoma presented for an OLT. A bedside transthoracic echocardiography (TTE) was performed immediately before the procedure and unexpectedly identified a ventricular septal defect (VSD). The patient and the surgical team agreed to proceed with the surgery as it was a time critical donation after circulatory organ death. We developed an intraoperative plan to optimize pulmonary and systemic pressures using vasoactive support, optimized mechanical ventilation, and used transesophageal echocardiography (TEE) for intraoperative monitoring. During reperfusion, considerable turbulent flows with air were noted in the right ventricle, but no air was visualized in the left ventricle. Color flow Doppler showed no reversal flow in the VSD. At the end of the procedure, the patient was extubated in the operating room without complication and was transferred to the transplant unit for recovery.
Our case highlights the importance of echocardiography in the perioperative assessment of patients undergoing liver transplantation. The TTE findings obtained immediately before the procedure and the real-time use of intraoperative TEE to modify our management during the critical phases of the transplant resulted in continuity of care and a good surgical outcome for this patient.
Core Tip: A liver transplant is a challenging case which can involve significant hemodynamic instability. It is also a situation where organ waitlists can prolong time to surgery leading to significant deterioration of the recipient’s condition. This can be compounded by any unexpected cardiac findings diagnosed in the immediate preoperative period by echocardiography. Our findings of a ventricular septal defect on transthoracic echocardiography (TTE) led to a clinical dilemma of proceeding with surgery knowing there was a risk of paradoxical embolism or hypoxemia. On the other hand, rejecting a matched donation after circulatory death liver graft would have been a waste of precious resources. By using intraoperative transesophageal echocardiography (TEE) we carefully titrated intraoperative hemodynamics and prevented intracardiac shunting. Our case highlights the importance of bedside TTE as well as intraoperative TEE in patients undergoing orthotopic liver transplants.