Complications related to intraoperative transesophageal echocardiography in liver transplantation

Abstract

PurposeIntraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated.MethodsWe retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida).ResultsOf the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/μL; and fibrinogen, 237.8 (127.6) mg/dL.ConclusionTEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.

Bleeding Outcomes Following Transesophageal Echocardiography in Patients With Cirrhosis and Esophageal Varices

“…Although currently published guidelines indicate that esophageal varices represent a relative contraindication to performing transesophageal echocardiography, (1) these recommendations are based almost entirely on expert opinion, as there is scant literature evidence to support this guidance. To date, most investigations regarding the risk of TEE in patients with esophageal varices are retrospective observational studies of overt hemorrhage following intra-operative (2)(3)(4)(5)(6) or non-intraoperative (7)(8)(9) TEE involving small cohorts (Table 6). In aggregate, these reports suggest that the incidence of overt postprocedural bleeding is low (0%-0.4%); however, their small size, heterogeneity, variably defined endpoints, and absence of a comparator cohort makes extrapolation difficult.…”

“…However, scant evidence exists to support the utility or efficacy of this practice. Most reports that have attempted to quantify the risk of bleeding in patients with cirrhosis and esophageal varices consist of retrospective case series of TEE performed intra-operatively during orthotopic liver transplantation, (2)(3)(4)(5)(6) with meta-analysis indicating a pooled incidence of postprocedural bleeding of 1.4%. (7) Data regarding the outcomes of patients with cirrhosis and esophageal varices who undergo nonoperative TEE are limited to three small cases series encompassing a total of 58 patients, in whom no bleeding events were noted.…”

Bleeding Risk of Transesophageal Echocardiography in Patients With Esophageal Varices

“…Table 2 summarizes eligible studies and the baseline characteristics of the enrolled subjects. All eight studies were single-center case series, out of which five investigated intraoperative TEE in patients undergoing orthotopic liver transplantation, [4][5][6][7][8] whereas the remaining three series (including ours) were in general clinical settings. 9,10 The predominant indication for TEE was hemodynamic monitoring during surgery (90%), followed by investigation for suspected infective endocarditis (7%).…”

Safety of Transesophageal Echocardiography in Patients with Esophageal Varices

“…Transesophageal echocardiogram (TEE) is a safe procedure with a complication rate <0.5% and mortality rate <0.01%. [1][2][3][4] Patients with cirrhosis pose an increased risk given the prevalence of coagulopathy and esophageal varices. No current recommendations exist on which of these patients require an esophagogastroduodenoscopy (EGD) prior to TEE.…”