Cardiac arrest during adult liver transplantation: A single institution's experience with 1238 deceased donor transplants

Abstract

Liver transplantation (LT) is one of the highest risk noncardiac surgeries. We reviewed the incidence, etiologies, and outcomes of intraoperative cardiac arrest (ICA) during LT. Adult cadaveric LT recipients from January 1, 2001 through December 31, 2009 were reviewed. ICA was defined as an event requiring either closed chest compression or open cardiac massage. Cardiac arrest patients who recovered with only pharmacological interventions were excluded. Data included etiologies and outcomes of ICA, intraoperative deaths (IDs) and hospital deaths (HDs), and potential ICA risk factors. ICA occurred in 68 of 1238 LT recipients (5.5%). It occurred most frequently during the neohepatic phase (60 cases or 90%), and 39 of these cases (65.0%) experienced ICA within 5 minutes after graft reperfusion. The causes of ICA included postreperfusion syndrome (PRS; 26 cases or 38.2%) and pulmonary thromboembolism (PTE; 24 cases or 35.3%). A higher Model for End-Stage Liver Disease (MELD) score was found to be the most significant risk factor for ICA. The ID rate after ICA was 29.4% (20 cases), and the HD rate was 50.0% (34 cases). The 30-day patient survival rate after ICA was 55.9%, and the 1-year survival rate was 45.6%: these rates were significantly lower (P < 0.001) than those for non-ICA patients (97.4% and 85.1%, respectively). In conclusion, the incidence of ICA in adult cadaveric LT was 5.5% with an intraoperative mortality rate of 29.4%. ICA most frequently occurred within 5 minutes after reperfusion and resulted mainly from PRS and PTE. A higher MELD score was identified as a risk factor.

Review of anesthesia in liver transplantation

“…112,113 The incidence of cardiac arrest during deceased donor LT procedure is reported to be 3.3% 114 to 5.5%, 115 with a high mortality of about 50%. 114 The incidence of cardiac arrest in LDLT is about 1.0%. 114 Both figures are remarkably higher in comparison with that of noncardiac and non-LT surgery, whose incidence was about 0.01% 116 to 0.043%.…”

“…114 The incidence of cardiac arrest in LDLT is about 1.0%. 114 Both figures are remarkably higher in comparison with that of noncardiac and non-LT surgery, whose incidence was about 0.01% 116 to 0.043%. 117 Preoperative assessments of the heart performance and ischemic CAD are necessary.…”

Serum acidosis prior to reperfusion facilitates hemodynamic recovery following liver transplantation

“…As a result, the sinus node as well as myocardial and pulmonary vascular structures are immediately exposed to potentially toxic contents of the revascularized graft. This results in a profound decline in myocardial contractility, bradyarrhythmias, and a rapid, substantial drop in systemic vascular resistance, leading to hemodynamic collapse and even cardiac arrest in selected cases [1]. In order to prevent catastrophic post-reperfusion hemodynamic effects, several techniques such as on-field graft flushing, gradual reverse Abstract Introduction Reperfusion is the most critical event during liver transplantation, and sustained leakage of acidic preservation solution from the liver graft contributes to marked hemodynamic instability.…”

“…This unique event occurs with the unclamping of the portal vein when acidic, cold, and hyperkalemic preservation solution is released from the ischemic liver graft into the recipient's circulation. The heart is the first organ to be exposed to the graft effluent, frequently resulting in a blunting of cardiac contractility and slowing of the heart rate, often leading to intraoperative cardiac arrest[1]. In addition to the toxicity of the chemicals in the effluent, resumption of the supply of oxygen to ischemic hepatocytes, endothelial cells, and Kupffer cells induces the production of massive numbers of oxygen free radicals, further aggravating hepatocyte injury and causing ischemia-reperfusion injury of the graft.…”

Extracorporeal membrane oxygenation as a rescue device for postreperfusion cardiac arrest during liver transplantation

“…1,2 The majority of cardiac arrests occur during the neohepatic phase, especially during reperfusion, and most are caused by either postreperfusion syndrome or pulmonary thromboembolic events. 2 Almost 20% of patients with intraoperative cardiac arrest cannot be successfully resuscitated and do not regain a spontaneous rhythm and circulation. Of those who regain a spontaneous rhythm and circulation with cardiopulmonary resuscitation (CPR), more than 12% will not survive the surgery.…”