Intracardiac Thrombosis during Adult Liver Transplantation

Intracardiac thrombosis (ICT) and pulmonary embolism (PE) during adult liver transplantation are rare but potentially lethal complications. They are often overlooked because of significant diagnostic challenges. The combination of hemodynamic compromise and transesophageal echocardiography (TEE) findings allows for correct diagnosis. A large variety of putative risk factors for ICT and PE have been suggested, but these events are considered to be multifactorial. There are different proposed treatment modalities for these devastating complications. Unfortunately, in spite of growing knowledge in this area, intraoperative and postoperative mortalities remain very high. The retrospective nature of the study of these events makes the case reports extremely valuable. 1. Introduction Orthotopic liver transplantation (OTL) is a major surgical procedure which usually involves significant blood loss secondary to coagulation disturbances typical of end stage liver disease. In addition, hyperfibrinolysis can occur intraoperatively, leading to more bleeding complications. In contrast to bleeding coagulopathies, intraoperative thrombotic complications are less frequently encountered but deserve special attention because of possible life threatening events. We are reporting a case of intracardiac thrombosis during OLT presented as a sudden cardiac arrest during the neohepatic stage. Patient’s family permission was obtained to publish this case report. 2. Case Presentation A 67-year-old, 78？kg, 176？cm man with a history of hypertension, diabetes mellitus, and decompensated liver disease secondary to hepatitis C virus (HCV) with portal hypertension, ascites, and hepatic encephalopathy presented for retransplantation with an MELD score of 31. He had undergone liver transplantation 18 months previously that was complicated by a severe recurrence of HCV infection, partially responding to therapy with interferon and ribavirin. Relevant laboratory studies revealed 82？g/L hemoglobin, 129.6？μmol/L creatinine, 165.87？μmol/L total bilirubin, 2.7 INR, 26.7？sec. prothrombin time (PT), 56？sec. partial thromboplastin time (PTT), 59,000 × 109/L platelets. Preoperative dobutamine stress test demonstrated normal left and right ventricular functions without evidence of ischemia. After preoxygenation, anesthesia was induced with 2？mg midazolam, 250？mcg fentanyl, 60？mg propofol, and 10？mg vecuronium. After intubation, two additional 16？g peripheral intravenous catheters, a radial arterial catheter and an 8.5 French introducer with pulmonary artery catheter, were placed. The dissection