Extracorporeal membrane oxygenation as a rescue device for postreperfusion cardiac arrest during liver transplantation

Abstract

TO THE EDITORS:Intraoperative cardiac arrest is a dreaded complication of liver transplantation with a poor outcome. 1,2 The majority of cardiac arrests occur during the neohepatic phase, especially during reperfusion, and most are caused by either postreperfusion syndrome or pulmonary thromboembolic events. 2 Almost 20% of patients with intraoperative cardiac arrest cannot be successfully resuscitated and do not regain a spontaneous rhythm and circulation. Of those who regain a spontaneous rhythm and circulation with cardiopulmonary resuscitation (CPR), more than 12% will not survive the surgery. The mortality of intraoperative cardiac arrest increases exponentially with the duration of CPR. If spontaneous rhythm and circulation are not restored rapidly, the prognosis is usually poor. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used as an extension of CPR in many clinical scenarios with varying success. We describe a successful case of the use of VA-ECMO to treat postreperfusion cardiac arrest and discuss practical aspects of using VA-ECMO as rescue CPR during liver transplantation. CASE REPORTA 61-year-old man with hepatitis B cirrhosis and hepatocellular carcinoma underwent deceased donor liver transplantation. He had previously undergone transarterial chemoembolization of the hepatocellular carcinoma and esophageal banding for esophageal varices. His physiologic Model for End-Stage Liver Disease score was 8 (serum creatinine 5 0.66 mg/dL, total bilirubin 5 0.9 mg/dL, and international normalized ratio 5 1.2). He was well compensated and reported good exercise tolerance with no symptoms of cardiac disease. A transthoracic echocardiogram 3 months before surgery demonstrated a left ventricular ejection fraction of 60% to 65%, normal biventricular systolic function, and no valvular pathologies. There was no evidence of wall motion abnormalities on a technetium-99m sestamibi pharmacologic stress test, which was also performed 3 months before surgery.A suitable standard criteria donor organ was identified (a 25-year-old woman who had a subarachnoid hemorrhage). The liver graft was procured and coldpreserved in a standard fashion without a perfusion circuit. The cold ischemia time of the graft was 5 hours 15 minutes, and the warm ischemia time was 47 minutes.The recipient was brought into the operating room, and after induction of general anesthesia, left radial and right femoral arterial catheters were placed along with a right internal jugular introducer with a pulmonary artery catheter without any complications. Initial intraoperative laboratory values were unremarkable. The dissection phase proceeded without complications and without the need for blood products. The patient tolerated clamping of the inferior vena cava and removal of the native liver with only low-dose vasopressor support (norepinephrine at 1 mg/minute and vasopressin at 1 U/hour). During the anhepatic phase, the patient remained hemodynamically stable and required slowly increasing doses of vasopressors with peak doses o...

Prolonged Intraoperative Cardiac Resuscitation Complicated by Intracardiac Thrombus in a Patient Undergoing Orthotopic Liver Transplantation

“…7,8 Case reports exist of profound ventricular dysfunction being successfully treated with ECMO or CPB with subsequent return of normal ventricular function. 8,32 Our case demonstrates that prolonged ACLS may be warranted in liver transplantation, that early clot identification with TEE and administration of heparin may help prevent clot expansion, and if this fails, tPA may be considered. If return of spontaneous circulation does not occur in a timely fashion, ECMO or CPB should be considered to ensure end organ perfusion.…”

Extracorporeal membrane oxygenation support following liver transplantation—A case series

“…Multiple case reports from around the world have described the use of ECMO in patients receiving liver transplantation at various stages in the perioperative period including early after allograft reperfusion . The largest to date case series has been reported by Park et al from South Korea.…”

Use of intra‐aortic counterpulsation in cardiogenic shock post‐liver transplantation

“…Tejani et al. have reported their experience with using ECMO for the rescue of a patient, a 61‐year‐old male with hepatitis B cirrhosis, who suffered cardiopulmonary arrest ~ 24 minutes after graft reperfusion . He did not respond to 5 minutes of CPR that included multiple vasopressors, five internal defibrillation attempts, and intracardiac epinephrine.…”

“…Venous‐arterial ECMO (V‐A ECMO) was initiated and maintained for ~48 hours. His OLT was completed and he ultimately was discharged with normal cardiac, graft, and neurologic function …”