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LETTER TO THE EDITOR

Fatal Right Ventricular Failure with Intracardiac Thrombus Formation During Liver Transplantation Not Apparent on Postmortem Examination

Department of Anesthesia, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, MA, jhudcova{at}tufts-nemc.org

To the Editor:

Lerner et al. (1) recently summarized cases involving thromboembolism during orthotopic liver transplantation with and without the use of antifibrinolytic drugs. We report a unique case in which transesophageal echocardiography (TEE) was very useful.

Our patient was a 51-yr-old man with hepatitis C cirrhosis, a Model for End-Stage Liver Disease score of 35, severe encephalopathy for the previous 3 wk, renal insufficiency, and diabetes mellitus who presented for orthotopic liver transplantation. His preoperative course was complicated by paroxysmal atrial fibrillation and ventricular tachycardia. Intraoperative TEE showed an ejection fraction of 45% without regional wall motion abnormalities. Adhesions from previous surgery prolonged the preanhepatic phase, which was hemodynamically uneventful for the first 2 h. Continuing coagulopathy required us to constantly administer blood products. We gave no antifibrinolytic drugs.

Two hours into the surgery the patient became acutely hypotensive. TEE revealed right ventricular dysfunction with bulging of the interatrial and interventricular septum. Thirty minutes later a second hypotensive episode occurred. TEE showed new thrombus formation in the right atrium rapidly expanding into the right ventricle. Despite aggressive inotropic support, the patient died of acute right ventricular failure.

Postmortem examination did not demonstrate any thromboembolus within the heart or pulmonary vasculature but did confirm acute right ventricular dilation without infarction. We assume that the complex hemostatic derangements of end-stage liver disease, which affect anticoagulation as well as procoagulation, probably facilitated intracardiac thrombus formation during low-flow hemodynamic instability in this severely debilitated patient. Postmortem fibrinolysis of a fresh thrombus could be one explanation for the autopsy result. Without unambiguous evidence of thrombus from the transthoracic echocardiography, we would have been unable to explain the abrupt hemodynamic compromise and subsequent demise of this patient.

Reference

1. Lerner AB, Sundar E, Mahmood F, et al. Four cases of cardiopulmonary thromboembolism during liver transplantation without the use of antifibrinolytic drugs. Anesth Analg 2005;101:1608–12.[Abstract/Free Full Text]

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