Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States

Abstract

Background: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18–80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2–4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05–3.98; P = .0386), BMI ≥40 (2.16 [1.12–4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30–39: 1.75 [1.09–2.79], P = .02; MELD ≥40: 2.73 [1.53–4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75–5.34], P < .001), living donors (2.13 [1.16–3.89], P = .014), and reoperation (1.87 [1.13–3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Preoperative echocardiography as a prognostic tool for liver transplant in patients with hypertrophic cardiomyopathy

“…25 Patients with HCM in our study also appeared to have higher rates of ICA and perioperative cardiopulmonary complications (Table 2) than all LT patients in a multicenter study. 26 Two patients in our study experienced ICA; one patient who died in the operating room, which was similar to the result reported by Smith et al 26 22 and are listed in the Box. Previously published data for patients not undergoing LT showed that TEE was rarely used for patients with HCM undergoing general surgery.…”

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

“…Catastrophic cardiopulmonary collapse is a risk at any stage of transplantation. Intraoperative cardiac arrest (ICA) occurs less frequently in LDLT than in DDLT (1‐2.4% vs. 3‐3.6%) 76,77 . ICA most commonly occurs secondary to PRS, hyperkalemia, and bleeding at reperfusion.…”

“…However, ICA during dissection and the anhepatic phase may also occur due to hemorrhage, intracardiac thrombus (ICT), or pulmonary thromboembolism (PTE) 76,78 . In a large, multicenter, retrospective review, LDLT was a risk factor associated with ICA (OR 2.13; 95% CI [1.16‐3.89]; P = .014) 77 . Though the association between LDLT and ICA was based on small sample size (396 patients), outcomes from LDLT patients with ICA were promising, with a lower intraoperative mortality rate than DDLT patients (.5% vs. 1.1%) 77 …”

Proceedings of the 26th Annual Virtual Congress of the International Liver Transplantation Society

“…For the perioperative considerations, intraoperative cardiac arrest is a feared complication with reported rate of 3.7% and in almost 50% of the cases it is associated with the postreperfusion syndrome. 31 Dr Wagener, Columbia University, discussed the AHA guidelines to consider the early use of extracorporeal membrane oxygenation, which was demonstrated to have a higher probability of return to spontaneous circulation. 32 Dr Findlay, Mayo Clinic, presented new diagnostic criteria for cirrhotic cardiomyopathy in end-stage liver disease from the Cirrhotic Cardiomyopathy Consortium during the Liver Intensive Care Group of Europe symposium.…”