Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients

Abstract

Liver allograft recipients may develop a hyperdynamic circulation and cardiac electrophysiologic abnormalities. The incidence of severe ventricular arrhythmias in liver allograft recipients during pulmonary artery (PA) catheterization was determined. One hundred five liver allograft recipients were studied prospectively; 5 of the patients with preexisting valvular heart disease, ischemic heart disease, or arrhythmias were excluded. Severe ventricular arrhythmia, defined as 3 or more consecutive ventricular premature beats occurring at a rate of Ͼ100 per minute, was observed in 37.0% of the patients during insertion of the catheter and in 25.0% of the patients during removal of the catheter. Two patients developed ventricular tachycardia, and 2 developed ventricular fibrillation; the arrhythmias in these 4 patients did not respond to appropriate pharmacological treatment but resolved promptly after removal of the PA catheter. The catheter transit time from the right ventricle to the pulmonary capillary wedge position was longer in patients with severe ventricular arrhythmia than in those without this arrhythmia (91.6 Ϯ 103. Liver transplantation is commonly associated with the administration of large volumes of fluid and massive hemorrhaging; predisposing factors include abnormalities of blood coagulation, the presence of numerous collateral vessels, and prolonged periods of surgery. Patients with end-stage chronic liver disease have a hyperdynamic circulation, features of which include increased cardiac output, tachycardia, and decreased systemic vascular resistance (SVR). These changes are associated with extensive arteriovenous communications and release of systemic vasodilators, such as glucagon, nitric oxide, ferritin, and vasoactive intestinal polypeptide. 1 Severe pulmonary hypertension or intrapulmonary arteriovenous shunts also occur in such patients. 2 Severe pulmonary hypertension is a contraindication to liver transplantation. Assessments of ventricular function are required throughout this procedure. Accordingly, in most centers, a pulmonary artery (PA) catheter is inserted routinely to evaluate cardiac function. The development of arrhythmias during the insertion of a PA catheter in patients undergoing cardiovascular surgery has been reported 3,4 (Fig. 1). However, the incidence of arrhythmias and hemodynamic changes in relation to the placement of a PA catheter in liver allograft recipients is unknown. Our experience with such patients suggests that the development of an arrhythmia commonly occurs during the insertion and removal of the catheter. The aim of this study was to examine prospectively arrhythmias and hemodynamic changes associated with PA catheterization in liver allograft recipients and to investigate possible factors responsible for these complications. PATIENTS AND METHODSThis study was approved by the local institutional review board on human studies; informed consent was

Early echocardiographic detection of a massive intracardiac thrombus in a patient scheduled for orthotopic liver transplantation

“…Nevertheless, there is no evidence that PAC improves outcome in the perioperative and critical care setting [3]. Gwak et al [4] reported in a series of 105 patients undergoing OLT an incidence of 70% arrhythmias during PAC insertion. Of these, 33% were classified as benign and 37% classified as severe arrhythmia (defined as three or more consecutive premature ventricular beats occurring at a rate of 100 bpm).…”

Video Fluoroscopy for Positioning of Pulmonary Artery Catheters in Patients Undergoing Cardiac Surgery

“…This minimizes the risk of PA perforation through inadvertent catheter "wedging." Prolonged catheterization time also is a recognized risk factor for ventricular arrhythmias during PAC insertion, 5,6 and excessive insertion length is the major contributing factor to catheter knotting. Hence, the use of fluoroscopy during PA insertion in cardiac surgery patients at higher risk of a PAC-related complication is a pragmatic, rational, and feasible intervention to minimize complications.…”

Perioperative Monitoring in Liver Transplant Patients

“…11,12 The PAC however, might be inaccurate if it is not positioned correctly and may not reflect changes in intravascular volume rapidly enough. With reported hazards of PAC insertion like ventricular arrhythmias, 13 and due to availability of less invasive monitoring tools, the use of PAC is declining. It is now increasingly reserved, for those cases where there is a suspicion of porto pulmonary hypertension, 14 as severe pulmonary hypertension (mPAP > 45) is associated with high perioperative mortality and, if not successfully treated, is a contraindication to LT. 15 Standard hemodynamic monitoring, such as arterial pressure monitoring, can also be extended for the assessment of CO, preload and afterload.…”