Devastating intracardiac and aortic thrombosis: a case report of apparent catastrophic antiphospholipid syndrome during liver transplantation

Gologorsky, Edward; Andrews, David; Gologorsky, Angela; Sampathi, Venkata; Sundararaman, Lalitha; Govindaswamy, Radhika; Raveh, Yehuda; Tzakis, Andreas G.; Pretto, Ernesto A.

doi:10.1016/j.jclinane.2010.07.007

Cited by 15 publications

(13 citation statements)

References 33 publications

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“…It may be prudent to consider the administration of t‐PA as soon as bilateral ICT is seen because it could be lifesaving. Gologorsky et al also described aortic root and bilateral ICT in a patient with antiphospholipid syndrome. We speculate that for a bilateral cardiac thrombus, a process such as this may be an occult cause.…”

Section: Discussionmentioning

confidence: 95%

Intracardiac thrombosis during liver transplant: A 17‐year single‐institution study

Peiris¹,

Pai²,

Aniskevich³

et al. 2015

Liver Transpl

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Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right-and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.

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Section: Discussionmentioning

confidence: 95%

Intracardiac thrombosis during liver transplant: A 17‐year single‐institution study

Peiris¹,

Pai²,

Aniskevich³

et al. 2015

Liver Transpl

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“…Although intraoperative thromboembolic phenomena were uncommon (estimated ˜1%-1.5%), 4,17 associated mortality was high. In an extensive systematic review (74 cases), Warnaar et al noted very high morality (68% overall) in cases of intraoperative PE, including intracardiac thrombosis.…”

Section: Thromboembolic Phenomena After Liver Transplantationmentioning

confidence: 94%

Do Postliver Transplant Patients Need Thromboprophylactic Anticoagulation?

Mukerji

Karachristos

Maloo

et al. 2014

Clin Appl Thromb Hemost

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Postoperative thromboprophylactic anticoagulation against Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) is standard of care with current evidence-based guidelines. However, majority of liver transplant (LT) patients have thrombocytopenia and/or prolonged INR before surgery. Studies or guidelines regarding role of prophylactic anticoagulation after LT are lacking. There is a need to balance the risk of thrombosis with significant hemorrhage, implying those needing transfusion or return to OR due to bleeding. We conclude that after LT, anticoagulation is not required routinely for DVT/PE prophylaxis. Rather, it is indicated in specific circumstances, chiefly for prophylaxis of hepatic artery thrombosis or portal vein thrombosis in cases with use of grafts, pediatric cases, small size vessels, Budd Chiari syndrome, amongst others.

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“…82 For patients with accompanying severe underlying disease or undergoing high bleeding risk surgery, standard monitoring, and also invasive monitoring, such as central venous pressure and pulmonary artery pressure measurements, or even transoesophageal echocardiography for detecting severe intracardiac thrombosis, may be required. 15,83 Anaesthesiologists should be aware that patients with APS can develop severe complications if CAPS is triggered during surgery. 83 The most common triggering factor is infection, which can subsequently progress to septic shock.…”

Section: Preoperative Considerationsmentioning

confidence: 99%

Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery

Kim

Ryu

et al. 2020

J Int Med Res

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Antiphospholipid syndrome (APS) is an acquired thrombotic autoimmune disorder that is clinically characterized by the development of thrombosis and obstetric morbidities in patients with antiphospholipid antibodies. Due to hypercoagulability, the focus of management is anticoagulation for the prevention of thrombosis and its recurrence. When such patients undergo surgery, however, the underlying risk of thrombosis increases as a result of anticoagulant withdrawal, immobilization, and/ or intimal injury. Conversely, there is also an increased risk of bleeding due to thrombocytopaenia, possible disseminated intravascular coagulation, or progression to catastrophic APS, as a result of excessive anticoagulation, surgery, and infection. Measures for appropriate perioperative anticoagulation are discussed in this review, as well as anaesthetic considerations for preventing perioperative complications in patients with APS undergoing non-cardiac surgery.

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Devastating intracardiac and aortic thrombosis: a case report of apparent catastrophic antiphospholipid syndrome during liver transplantation

Cited by 15 publications

References 33 publications

Intracardiac thrombosis during liver transplant: A 17‐year single‐institution study

Intracardiac thrombosis during liver transplant: A 17‐year single‐institution study

Do Postliver Transplant Patients Need Thromboprophylactic Anticoagulation?

Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery

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