Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review

Abstract

Summary. Background: Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). Methods: We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. Results: Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. Conclusion: Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P < 0.001). Intraoperative PE and ICT during OLT appear to have multiple etiologies and may occur unexpectedly at any time during the procedure.

Incidental intracardiac thromboemboli during liver transplantation: Incidence, risk factors, and management

“…1,15,16 It is believed that intraoperative ICTs during OLT are greatly underdiagnosed and underreported. 9 The need for TEE monitoring is an obstacle for the accurate diagnosis of intraoperative ICTs (particularly those without significant hemodynamic changes).…”

“…1,2 Most reported cases have a clinical presentation characterized by a sudden increase in the pulmonary artery (PA) pressure, severe hypotension, cardiovascular collapse, or cardiac arrest. The thromboemboli in these cases are usually described as large, massive, severe, or fatal; these terms refer to the clot size, the impact on hemodynamics, or the patient outcomes (the term massive is used throughout this report).…”

Monitoring of haemostasis in liver transplantation: comparison of laboratory based and point of care tests

“…During orthotopic liver transplantation, prothrombin time and activated partial prothrombin time can be reliably determined by the Hemochron device, while thrombelastometry allows assessment of platelet count and fibrinogen concentration. Coagulation abnormalities during orthotopic liver transplanation are characterised by decreased coagulation factors, antifibrinolytic factors and endogeneous anticoagulant factors [1], all of which represent a major perioperative challenge as both bleeding episodes and thrombotic events can be precipitated [2,3]. Accordingly, monitoring of the coagulation system during liver transplantation is important.…”

Emergent Management of Intracardiac Thrombosis during Liver Transplantation

“…Once diagnosed, treatment is challenging and outcomes vary. Intracardiac thrombus (ICT) formation during orthotopic liver transplantation (OLT) is associated with a mortality rate as high as 68% [2]. A small number of published reports describe the successful use of recombinant tissue plasminogen activator (rTPA) as well as thrombectomy in the treatment of both intracardiac and pulmonary thrombi [3].…”