Role of Transesophageal Echocardiography in the Diagnosis of Multi-chamber Intracardiac Thrombosis During Liver Transplantation: A Case Series

Abstract

Intra-cardiac thrombosis is one of the most devastating complications during liver transplantation. In the majority of cases, ICT, followed by massive pulmonary embolism, is commonly occurring shortly after liver graft reperfusion, but it has been reported to occur at any stage of the surgery. We present a series of 3 cases of intra-cardiac thrombosis during orthotopic liver transplantation surgery, including a case of four-chamber intra-cardiac clot formation during the pre-anhepatic stage. This article represents a single-centre 14 year-long experience. Intra-operative TEE is the gold standard to diagnose intra-cardiac thrombosis, monitoring its size, location and dynamics, as well as myocardial performance and the effects of resuscitation efforts.

Low‐dose tissue plasminogen activator is safe and effective in treating major intracardiac thrombosis in liver transplant recipients

“…One center showed short‐term survival after ICT was 33.3% prior to adopting TEE use and improved to 64% after instituting TEE 13 . TEE is necessary for accurately diagnosing ICT as well as guiding supportive and thrombolytic treatment of ICT 1,3,10,13,15–17 . We used TEE to diagnose all patients with ICT, to manage ICT treatment, and to confirm the resolution of ICT.…”

“…13 TEE is necessary for accurately diagnosing ICT as well as guiding supportive and thrombolytic treatment of ICT. 1,3,10,13,[15][16][17] We used TEE to diagnose all patients with ICT, to manage ICT treatment, and to confirm the resolution of ICT. Toward the end of the study period, ECMO became available for rescue of cardiorespiratory failure in LT recipients.…”

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

“…Reperfusion has previously been reported as the most common phase for ICT to occur. [2,3,5,[17][18][19] Subclinical thromboemboli have been observed on TEE at reperfusion in the majority of transplantations in several studies. [19][20][21] In fact, these microemboli were observed in more patients when VVB was not used compared with when VVB was used, suggesting that stasis during the IVC clamp and air in the donor vessels may contribute to observed debris in the right atrium at reperfusion.…”

Perioperative management of adult living donor liver transplantation: Part 1 – recipients

“…ICT and PTE may present as cardiac arrest or severe hypotension with a concurrent increase in pulmonary arterial pressure and central venous pressure 81 . TEE in LDLT may aid in the early diagnosis of ICT/PTE with evidence of right ventricular dilation and failure and new or worsening severe tricuspid regurgitation, sometimes with thrombus visible in the cardiac chambers 81–84 . Early diagnosis of ICT/PTE allows for prompt and targeted treatment with inotropic medications, pulmonary vasodilators, heparin, and thrombolytics 85 …”