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This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016–2020) compared with the pre‐TEE era (2011–2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End‐Stage Liver Disease–sodium (MELD‐Na) scores, pretransplant hospitalization, malignancy, drug‐induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver–kidney transplantation. The patients with ICT were similar, except patients in the pre‐TEE era had higher MELD‐Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre‐TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30‐day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p = 0.002). The 30‐day mortality rate was 36% (9/25) in the TEE era (p = 0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.

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BackgroundIn the United States, firearms now rank as the second-leading cause of death among children and adolescents, trailing only motor-vehicle accidents. Prior reports have calculated that 87% of all children aged 0-14 killed by firearms in high-income countries are US children. This study sets out to determine how rates of gun ownership, surrogate markers for the number of guns in circulation and strictness of firearm-related correlated with firearm-related mortality among both juvenile and overall populations at the state level.MethodsFirearm-associated mortality rates among juveniles, as well as among all ages, were obtained for each US state from the Centers for Disease Control and Prevention (CDC). The number of National Firearms Act weapons and federal firearms licensees for each state was taken from the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). State-level gun ownership rates, poverty rates and unemployment rates were procured from the RAND corporation, US. Census Bureau and US Department of Labor, respectively. Mental health data was taken from the CDC’s behavioral risk factor surveillance system. Gifford Center Scorecard Rankings were used a relative measure of firearm law strictness. Bivariate linear regression was used to model the relationships between firearm-associated mortality as well as ATF registered weapons, ATF federal firearm licensees, Giffords Center scorecard rankings and gun-ownership rates. Multivariate analysis was then performed to control for state-level differences in poverty rates, unemployment rates and poor mental health.ResultsUnadjusted analysis showed that more ATF federal firearm licensees, higher gun ownership rates and more lenient gun laws were associated with increased rates of firearm-associated mortality among juveniles. Similarly, all 3 such measures as well as more ATF registered weapons were associated with increased rates of firearm-related death among overall populations. In the adjusted analysis, more ATF registered weapons, more ATF federal firearm licensees, higher gun ownership rates and more lenient firearm laws were all associated with higher rates of firearm-related mortality among both juvenile and overall populations. ConclusionsIn order to reduce the risk of firearm-associated death among children, US policy makers and stakeholders should focus on implementing more restrictive firearm laws and decreasing gun ownership rates.

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