Risk Factors for Intracardiac Thrombus During Liver Transplantation

Abstract

Intracardiac thrombus (ICT) is an intraoperative complication with high mortality that occurs during orthotopic liver transplantation (OLT). Patients with end‐stage liver disease have compromised coagulation pathways, and when combined with stressors of surgery, thrombi can form. However, it is unknown which patients are most likely to develop ICT. We performed a retrospective cohort study of all OLT patients at our hospital from 2010 to 2017 to identify risk factors for ICT. An analysis was performed with conventional bivariate tests and logistic regression. The incidence of ICT during OLT was 4.2% (22/528) with a 45.5% (10/22) mortality. Patients who developed ICT had higher physiologic Model for End‐Stage Liver Disease scores at the time of transplant (25.1 versus 32.4; P = 0.004), received grafts from donors with a higher body mass index (28.1 versus 32.2 kg/m2; P = 0.007), and had longer intraoperative warm ischemia times (53.1 versus 67.5 minutes; P = 0.001). The odds of developing ICT were significantly lower after administration of intravenous (IV) heparin prior to inferior vena cava (IVC) clamping compared with no administration of heparin (odds ratio, 0.25; 95% confidence interval, 0.08‐0.75; P = 0.01). In conclusion, the incidence of ICT at our institution is higher than previously reported, which may be explained by our routine use of transesophageal echocardiography. Although many factors associated with ICT in this study are nonmodifiable, administration of IV heparin prior to IVC cross‐clamping is modifiable and was found to be protective. Further studies will be needed to confirm findings and ultimately aid in preventing these lethal events.

The Challenging Management of an Intracardiac Thrombus in a Liver Transplant Patient at the Reperfusion Phase: A Case Report and Brief Literature Review

“…Other reports suggest that thrombectomy and/or thrombolysis may be associated with lower rates of patient mortality; although this trend has not been shown to be statistically significant. 4 , 5 Groose et al, 11 in a single retrospective study center, reported that the odds of developing ICT were significantly lower following the administration of intravenous heparin before IVC clamping and thus concluded heparin to be protective. This would suggest that venous stasis, vascular clamping, and reperfusion could contribute to clot formation ( Video 2, SDC , http://links.lww.com/TXD/A359 ).…”

Research priorities in liver transplant anesthesiology: Results of a survey of liver transplant anesthesiologists

“…16 Patients with higher MELD scores are sicker by definition, and may be prone to more severe complications such as intraoperative thromboembolism. 17 As such, we speculate that practitioners' research priorities may reflect their local experience with this rare but catastrophic complication of transplant, but our data do not allow for us to do more than speculate.…”

“…Patients who undergo liver transplant in the Northeast, for example, are transplanted with higher Model for End‐Stage Liver Disease (MELD) scores, compared to patients in the south 16 . Patients with higher MELD scores are sicker by definition, and may be prone to more severe complications such as intraoperative thromboembolism 17 . As such, we speculate that practitioners’ research priorities may reflect their local experience with this rare but catastrophic complication of transplant, but our data do not allow for us to do more than speculate.…”

Intraoperative intracardiac thrombus in liver transplantation: A 9‐year retrospective review focusing on treatment and outcomes

“…The incidence of ICT and/or PTE during OLT has been reported to be as low as 0.36% and as high as 6.25%. [1][2][3][4] ICT can occur at any point during liver transplantation [1,2,5] and is associated with patient factors such as Model for End-Stage Liver Disease (MELD) score, donor body mass index, and organ warm ischemia time (WIT). [4] Although rare, ICT can be a catastrophic event leading to clinically significant hemodynamic instability, intraoperative cardiac arrest (ICA), or intraoperative death (IOD) and is associated with an intraoperative mortality rate of 45%-68%.…”

“…[1][2][3][4] ICT can occur at any point during liver transplantation [1,2,5] and is associated with patient factors such as Model for End-Stage Liver Disease (MELD) score, donor body mass index, and organ warm ischemia time (WIT). [4] Although rare, ICT can be a catastrophic event leading to clinically significant hemodynamic instability, intraoperative cardiac arrest (ICA), or intraoperative death (IOD) and is associated with an intraoperative mortality rate of 45%-68%. [2,4,5] When TEE is not present to confirm diagnosis, ICT is typically suspected when sudden hemodynamic collapse occurs in the setting of increased central venous pressure and pulmonary artery pressures on a pulmonary artery catheter, suggesting PTE.…”