Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA

Abstract

Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient-and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive.In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.

Abdominal Organ Transplantation: Noteworthy Literature in 2021

“…Bezinover and the leaders of the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of hemodynamic instability during LT and provided consensus statements with management recommendations. 49 Although most of the recommendations were based on observational studies or expert opinions, unique LT-associated cardiac conditions including vasoplegic syndrome, cardiomyopathies, and portopulmonary hypertension are thoroughly discussed.…”

New onset nonischemic cardiomyopathy post liver transplantation

“…This results in decreased preload, and, in conjunction with a pre-existing vasodilatation, hypotension [8] 2) Anhepatic phase. The hepatic artery, portal vein, and inferior vena cava are cross-clamped.…”

“…-Decrease in systolic arterial pressure -Decrease in pulmonary arterial systolic and diastolic pressure -Decrease in pulmonary capillary wedge pressure -Decrease in cardiac output and cardiac index -Increase in systemic vascular resistance -Increase in pulmonary vascular resistance Significant fluid boluses as well as inotrope and vasopressor administration may be required [8].…”

“…On intraoperative TEE, LV dysfunction with LVEF ≤ 45% was found in 4 out of 100 cases, two during anhepatic and two during the reperfusion phase [43]. In comparison of TEE findings in patients with (8) and without postreperfusion syndrome (16), there was no difference in cardiac function [44].…”

Optimizing Intraoperative Haemodynamics and Haemostasis to Enhance Recovery After Liver Transplantation for Cirrhosis in Adults

“…The incidence of coronary artery disease and impaired myocardial performance is common among such patients, and the combination of a preoperative ejection fraction less than 50%, prolongation of the QT interval, and diastolic dysfunction is strongly suggestive of underlying cirrhotic cardiomyopathy. 2,3 Right ventricular dysfunction seen in ESLD is usually associated with porto-pulmonary hypertension. Excess splanchnic nitric oxide production with profound systemic and splanchnic vasodilatation and sequestration of blood within the splanchnic circulation leads to a state of relative hypovolemia, systemic hypotension, and organ hypoperfusion.…”