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Early echocardiographic detection of a massive intracardiac thrombus in a patient scheduled for orthotopic liver transplantation
Journal of Clinical Anesthesia (2012) 24, 404–406
Case Report
Early echocardiographic detection of a massive intracardiac thrombus in a patient scheduled for orthotopic liver transplantation☆,☆☆ Haitham Mutlak MD (Fellow)a,⁎, Hans-Joachim Wilke MD, DEAA (Attending Anesthesiologist) a , Christian Moench MD, PhD (Attending Surgeon)b , Wolf-Otto Bechstein MD (Professor of Surgery)b , Gösta Lotz MD, DESA (Attending Anesthesiologist) a , Kai Zacharowski MD, FRCA (Professor of Anesthesiology)a , Thomas Iber MD, PhD (Attending Anesthesiologist) a a
Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Hospital, 60590 Frankfurt am Main, Germany b Department of General, Visceral and Transplantation Surgery, Goethe University Hospital, 60590 Frankfurt am Main, Germany Received 20 July 2011; revised 25 October 2011; accepted 16 November 2011
Keywords: Hemodynamic monitoring; Hepatocellular carcinoma; Orthotopic liver transplantation; Thrombus; Transesophageal echocardiography
Abstract Transesophageal echocardiography (TEE) in cases of orthotopic liver transplantation is gaining acceptance for intraoperative hemodynamic monitoring. The timepoint of TEE probe insertion varies and is based on the fear of bleeding complications in the setting of portal hypertension with esophageal varices. In this case, early insertion of the TEE probe and examination resulted in the early detection of a large intracardiac thrombus, and thus the cancellation of the planned procedure. This case highlights the potential value of early TEE examination in orthotopic liver transplantation. © 2012 Elsevier Inc. All rights reserved.
1. Introduction ☆
Supported by departmental funding only. Note: This article is published with the written consent of the patient. ⁎ Correspondence: Haitham Mutlak, MD, Goethe University Hospital Frankfurt, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern-Kai 7, 60590 Frankfurt am Main. Tel.: +49 69 6301 5998; fax: +49 69 6301 5881. E-mail address: [email protected] (H. Mutlak). ☆☆
0952-8180/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2011.11.004
The use of transesophageal echocardiography (TEE) in orthotopic liver transplantation (OLT) is an upcoming and promising tool for intraoperative hemodynamic monitoring. Important additional findings such as intracardiac thrombosis and pulmonary embolism (PE) may be made. Incidental intracardiac thrombus during OLT, if undetected, may cause catastrophic complications associated with very high
TEE in orthotopic liver transplantation
405
mortality. The etiology of intracardiac thrombus is variable, including, for example, tumor thrombus caused by a hepatocellular carcinoma or by the administration of antifibrinolytic drugs before surgery. The timepoint of TEE probe insertion varies and is based on the fear of bleeding complications in the setting of portal hypertension with esophageal varices. This case report describes a patient scheduled for liver transplantation, who had a massive intracardiac thrombus that was detected immediately following induction of anesthesia. Diagnosis of the thrombus led to cancellation of the planned OLT.
2. Case report A 68 year old man with hepatocellular carcinoma, which was first diagnosed in 2008, and liver cirrhosis (Child-Pugh A/MELD 8) was scheduled for OLT. Previous surgical history included a Billroth II gastrectomy on the basis of gastrointestinal bleeding. After diagnosis in 2008, right hemihepatectomy was performed for “resection as a bridge to transplant”. The patient was listed for transplantation in 2009 with an exceptional MELD (model for end-stage liver disease) score of 29. Cardiovascular and pulmonary status at the time of listing were without pathological findings. The last transthoracic echocardiography (TTE) was also performed at that time, approximately one year earlier, and did not show any pathology. Anesthesia induction included 0.25 mg of fentanyl and 200 mg of propofol, followed by 50 mg of rocuronium. After intubation, insertion of an arterial catheter, central venous catheter [8.5-French (Fr), 4 lumina], and an 8.5-Fr percutaneous sheath, the TEE probe was inserted. A massive intracardiac thrombus was detected in the midesophageal 4-chamber view and midesophageal bicaval view. Thrombus size was 5 × 2.5 cm without relation to the tricuspid valve or the interatrial septum. In the midesophageal bicaval view, the thrombus seemed to
Fig. 1 Bicaval view of the giant intracardiac thrombus (arrow). RA = right atrium, LA = left atrium, SVC = superior vena cava.
Fig. 2 Midesophageal 4-chamber view of the intracardiac thrombus (arrow). RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle.
evolve from the inferior vena cava (Figs. 1 and 2). These findings were shown to the transplant surgeon, after which the decision was made to cancel the procedure. The patient was transferred to the intensive care unit (ICU) and weaned from anesthesia and mechanical ventilation. A postoperative computed tomographic scan confirmed the thrombus, showing a partially congested superior vena cava and PE in the central right pulmonary artery, with a subtotal occlusion of the lower lobe arteries. After discharge from the ICU, the patient presented to an angiologist and was treated with antithrombotic medication to stop further thrombus growth. The thrombus in the vena cava was biopsied and histologically proved to be a hepatocellular carcinoma.
3. Discussion Anesthetic management of patients undergoing OLT is challenging and often complicated. The operative procedure predisposes to intraoperative cardiovascular instability, significant blood loss, and marked electrolyte, acid base, and hemostatic disturbances. Adverse intraoperative hemodynamic events are independently associated with poor outcome after OLT [1]. Incidental cardiac thrombosis in particular may lead to serious complications in OLT, including intraoperative death [2]. Our case highlights the value of intraoperative TEE. Routine use of TEE during OLT allows direct monitoring of right and left ventricular function and should be seriously considered a standard monitoring procedure. There is no generally agreed on standard for intraoperative hemodynamic monitoring during OLT. Some of the main methods are systemic arterial pressure, central venous pressure (CVP), pulmonary artery catheterization (PAC), pulse contour cardiac output, and TEE. As previously mentioned, multiple causes of sudden hemodynamic
406 instability during OLT demand careful assessment of cardiac preload and function. Until now, PAC is considered the “gold standard” for this purpose. Nevertheless, there is no evidence that PAC improves outcome in the perioperative and critical care setting [3]. Gwak et al [4] reported in a series of 105 patients undergoing OLT an incidence of 70% arrhythmias during PAC insertion. Of these, 33% were classified as benign and 37% classified as severe arrhythmia (defined as three or more consecutive premature ventricular beats occurring at a rate of 100 bpm). All arrhythmic episodes were self-limited. However, these data contributed to a trend favoring less invasive monitoring, such as CVP monitoring. TEE is gaining acceptance for real-time cardiac monitoring because it is relatively noninvasive and provides continuous visual information on preload, valvular function, and ventricular function. Furthermore, it may lead to an immediate diagnosis [5]. The usefulness of TEE in OLT has been described in multiple case reports in which hemodynamic instability was present due to PEs, intracardiac thrombi, cardiac tamponade, or hypertrophic obstructive cardiomyopathy [6-9]. In contrast to the previously mentioned case reports, in which incidental cardiac thrombosis was detected during the operative procedure, and likely caused by hypercoagulability, our case report describes a completely different scenario. Intracardiac thrombus was present and detected after induction of anesthesia but before the planned operative procedure. No hemodynamic instability was present at this time. If a PAC had been inserted, there would have been two clinical scenarios: the better one: the catheter slides past the thrombus without dislocating it, or the worst case scenario: the patient would have suffered from sudden cardiac death due to the migration of the thrombus. There is still controversy as to when TEE probe insertion should occur; either right after induction of anesthesia, after intraoperative portocaval shunting, or at the beginning of extracorporal circulation. Studies of TEE in OLT using initial and/or intraoperative reassessment have shown improved monitoring of volume status and myocardial function with significant improvement in therapy, leading to the conclusion that TEE use is safe, even when esophageal varices are present [5,10-12]. However, use of TEE requires experience. Training is not available in every transplantation center. In a survey by Wax et al, transplantation centers in the United States with more than 50 OLTs per year were surveyed about their TEE utilization [13]. Eighty-six percent of the anesthesiologists performed TEE in some or all OLT cases; however, most of them performed a limited scope examination. TEE skills were acquired
H. Mutlak et al. informally and only 12% of the TEE users were boardcertified in TEE performance. In summary, this case underlines the importance of TEE in the perioperative setting of OLT. TEE is not only a tool to guide hemodynamic management; it may also diagnose intracardiac thrombosis and PE. We believe that when preparing for OLT in patients with hepatocellular carcinoma, a follow-up TEE or TTE examination should be performed to update any TTE findings made at the time of listing, especially if the last report is older than one year.
References [1] Reich DL, Wood RK Jr, Emre S, et al. Association of intraoperative hypotension and pulmonary hypertension with adverse outcomes after orthotopic liver transplantation. J Cardiothorac Vasc Anesth 2003;17: 699-702. [2] Xia VW, Ho JK, Nourmand H, Wray C, Busuttil RW, Steadman RH. Incidental intracardiac thromboemboli during liver transplantation: incidence, risk factors, and management. Liver Transpl 2010;16: 1421-7. [3] Ozier Y, Klinck JR. Anesthetic management of hepatic transplantation. Curr Opin Anaesthesiol 2008;21:391-400. [4] Gwak MS, Kim JA, Kim GS, et al. Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients. Liver Transpl 2007;13:1451-4. [5] Burtenshaw AJ, Isaac JL. The role of trans-oesophageal echocardiography for perioperative cardiovascular monitoring during orthotopic liver transplantation. Liver Transpl 2006;12:1577-83. [6] Ellenberger C, Mentha G, Giostra E, Licker M. Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation. J Clin Anesth 2006;18:367-71. [7] Planinsic RM, Nicolau-Raducu R, Eghtesad B, Marcos A. Diagnosis and treatment of intracardiac thrombosis during orthotopic liver transplantation. Anesth Analg 2004;99:353-6. [8] Prah GN, Lisman SR, Maslow AD, Freeman RB, Rohrer RJ. Transesophageal echocardiography reveals an unusual cause of hemodynamic collapse during orthotopic liver transplantation–two case reports. Transplantation 1995;59:921-5. [9] Sibulesky L, Peiris P, Taner CB, Kramer DJ, Canabal JM, Nguyen JH. Intraoperative intracardiac thrombosis in a liver transplant patient. World J Hepatol 2010;2:198-200. [10] Costa MG, Chiarandini P, Della Rocca G. Hemodynamics during liver transplantation. Transplant Proc 2007;39:1871-3. [11] De Wolf A. Transesophageal echocardiography and orthotopic liver transplantation: general concepts. Liver Transpl Surg 1999;5: 339-40. [12] Hofer CK, Zollinger A, Rak M, et al. Therapeutic impact of intraoperative transoesophageal echocardiography during noncardiac surgery. Anaesthesia 2004;59:3-9. [13] Wax DB, Torres A, Scher C, Leibowitz AB. Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States. J Cardiothorac Vasc Anesth 2008;22: 811-3.
Case Report
Early echocardiographic detection of a massive intracardiac thrombus in a patient scheduled for orthotopic liver transplantation☆,☆☆ Haitham Mutlak MD (Fellow)a,⁎, Hans-Joachim Wilke MD, DEAA (Attending Anesthesiologist) a , Christian Moench MD, PhD (Attending Surgeon)b , Wolf-Otto Bechstein MD (Professor of Surgery)b , Gösta Lotz MD, DESA (Attending Anesthesiologist) a , Kai Zacharowski MD, FRCA (Professor of Anesthesiology)a , Thomas Iber MD, PhD (Attending Anesthesiologist) a a
Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Hospital, 60590 Frankfurt am Main, Germany b Department of General, Visceral and Transplantation Surgery, Goethe University Hospital, 60590 Frankfurt am Main, Germany Received 20 July 2011; revised 25 October 2011; accepted 16 November 2011
Keywords: Hemodynamic monitoring; Hepatocellular carcinoma; Orthotopic liver transplantation; Thrombus; Transesophageal echocardiography
Abstract Transesophageal echocardiography (TEE) in cases of orthotopic liver transplantation is gaining acceptance for intraoperative hemodynamic monitoring. The timepoint of TEE probe insertion varies and is based on the fear of bleeding complications in the setting of portal hypertension with esophageal varices. In this case, early insertion of the TEE probe and examination resulted in the early detection of a large intracardiac thrombus, and thus the cancellation of the planned procedure. This case highlights the potential value of early TEE examination in orthotopic liver transplantation. © 2012 Elsevier Inc. All rights reserved.
1. Introduction ☆
Supported by departmental funding only. Note: This article is published with the written consent of the patient. ⁎ Correspondence: Haitham Mutlak, MD, Goethe University Hospital Frankfurt, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern-Kai 7, 60590 Frankfurt am Main. Tel.: +49 69 6301 5998; fax: +49 69 6301 5881. E-mail address: [email protected] (H. Mutlak). ☆☆
0952-8180/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2011.11.004
The use of transesophageal echocardiography (TEE) in orthotopic liver transplantation (OLT) is an upcoming and promising tool for intraoperative hemodynamic monitoring. Important additional findings such as intracardiac thrombosis and pulmonary embolism (PE) may be made. Incidental intracardiac thrombus during OLT, if undetected, may cause catastrophic complications associated with very high
TEE in orthotopic liver transplantation
405
mortality. The etiology of intracardiac thrombus is variable, including, for example, tumor thrombus caused by a hepatocellular carcinoma or by the administration of antifibrinolytic drugs before surgery. The timepoint of TEE probe insertion varies and is based on the fear of bleeding complications in the setting of portal hypertension with esophageal varices. This case report describes a patient scheduled for liver transplantation, who had a massive intracardiac thrombus that was detected immediately following induction of anesthesia. Diagnosis of the thrombus led to cancellation of the planned OLT.
2. Case report A 68 year old man with hepatocellular carcinoma, which was first diagnosed in 2008, and liver cirrhosis (Child-Pugh A/MELD 8) was scheduled for OLT. Previous surgical history included a Billroth II gastrectomy on the basis of gastrointestinal bleeding. After diagnosis in 2008, right hemihepatectomy was performed for “resection as a bridge to transplant”. The patient was listed for transplantation in 2009 with an exceptional MELD (model for end-stage liver disease) score of 29. Cardiovascular and pulmonary status at the time of listing were without pathological findings. The last transthoracic echocardiography (TTE) was also performed at that time, approximately one year earlier, and did not show any pathology. Anesthesia induction included 0.25 mg of fentanyl and 200 mg of propofol, followed by 50 mg of rocuronium. After intubation, insertion of an arterial catheter, central venous catheter [8.5-French (Fr), 4 lumina], and an 8.5-Fr percutaneous sheath, the TEE probe was inserted. A massive intracardiac thrombus was detected in the midesophageal 4-chamber view and midesophageal bicaval view. Thrombus size was 5 × 2.5 cm without relation to the tricuspid valve or the interatrial septum. In the midesophageal bicaval view, the thrombus seemed to
Fig. 1 Bicaval view of the giant intracardiac thrombus (arrow). RA = right atrium, LA = left atrium, SVC = superior vena cava.
Fig. 2 Midesophageal 4-chamber view of the intracardiac thrombus (arrow). RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle.
evolve from the inferior vena cava (Figs. 1 and 2). These findings were shown to the transplant surgeon, after which the decision was made to cancel the procedure. The patient was transferred to the intensive care unit (ICU) and weaned from anesthesia and mechanical ventilation. A postoperative computed tomographic scan confirmed the thrombus, showing a partially congested superior vena cava and PE in the central right pulmonary artery, with a subtotal occlusion of the lower lobe arteries. After discharge from the ICU, the patient presented to an angiologist and was treated with antithrombotic medication to stop further thrombus growth. The thrombus in the vena cava was biopsied and histologically proved to be a hepatocellular carcinoma.
3. Discussion Anesthetic management of patients undergoing OLT is challenging and often complicated. The operative procedure predisposes to intraoperative cardiovascular instability, significant blood loss, and marked electrolyte, acid base, and hemostatic disturbances. Adverse intraoperative hemodynamic events are independently associated with poor outcome after OLT [1]. Incidental cardiac thrombosis in particular may lead to serious complications in OLT, including intraoperative death [2]. Our case highlights the value of intraoperative TEE. Routine use of TEE during OLT allows direct monitoring of right and left ventricular function and should be seriously considered a standard monitoring procedure. There is no generally agreed on standard for intraoperative hemodynamic monitoring during OLT. Some of the main methods are systemic arterial pressure, central venous pressure (CVP), pulmonary artery catheterization (PAC), pulse contour cardiac output, and TEE. As previously mentioned, multiple causes of sudden hemodynamic
406 instability during OLT demand careful assessment of cardiac preload and function. Until now, PAC is considered the “gold standard” for this purpose. Nevertheless, there is no evidence that PAC improves outcome in the perioperative and critical care setting [3]. Gwak et al [4] reported in a series of 105 patients undergoing OLT an incidence of 70% arrhythmias during PAC insertion. Of these, 33% were classified as benign and 37% classified as severe arrhythmia (defined as three or more consecutive premature ventricular beats occurring at a rate of 100 bpm). All arrhythmic episodes were self-limited. However, these data contributed to a trend favoring less invasive monitoring, such as CVP monitoring. TEE is gaining acceptance for real-time cardiac monitoring because it is relatively noninvasive and provides continuous visual information on preload, valvular function, and ventricular function. Furthermore, it may lead to an immediate diagnosis [5]. The usefulness of TEE in OLT has been described in multiple case reports in which hemodynamic instability was present due to PEs, intracardiac thrombi, cardiac tamponade, or hypertrophic obstructive cardiomyopathy [6-9]. In contrast to the previously mentioned case reports, in which incidental cardiac thrombosis was detected during the operative procedure, and likely caused by hypercoagulability, our case report describes a completely different scenario. Intracardiac thrombus was present and detected after induction of anesthesia but before the planned operative procedure. No hemodynamic instability was present at this time. If a PAC had been inserted, there would have been two clinical scenarios: the better one: the catheter slides past the thrombus without dislocating it, or the worst case scenario: the patient would have suffered from sudden cardiac death due to the migration of the thrombus. There is still controversy as to when TEE probe insertion should occur; either right after induction of anesthesia, after intraoperative portocaval shunting, or at the beginning of extracorporal circulation. Studies of TEE in OLT using initial and/or intraoperative reassessment have shown improved monitoring of volume status and myocardial function with significant improvement in therapy, leading to the conclusion that TEE use is safe, even when esophageal varices are present [5,10-12]. However, use of TEE requires experience. Training is not available in every transplantation center. In a survey by Wax et al, transplantation centers in the United States with more than 50 OLTs per year were surveyed about their TEE utilization [13]. Eighty-six percent of the anesthesiologists performed TEE in some or all OLT cases; however, most of them performed a limited scope examination. TEE skills were acquired
H. Mutlak et al. informally and only 12% of the TEE users were boardcertified in TEE performance. In summary, this case underlines the importance of TEE in the perioperative setting of OLT. TEE is not only a tool to guide hemodynamic management; it may also diagnose intracardiac thrombosis and PE. We believe that when preparing for OLT in patients with hepatocellular carcinoma, a follow-up TEE or TTE examination should be performed to update any TTE findings made at the time of listing, especially if the last report is older than one year.
References [1] Reich DL, Wood RK Jr, Emre S, et al. Association of intraoperative hypotension and pulmonary hypertension with adverse outcomes after orthotopic liver transplantation. J Cardiothorac Vasc Anesth 2003;17: 699-702. [2] Xia VW, Ho JK, Nourmand H, Wray C, Busuttil RW, Steadman RH. Incidental intracardiac thromboemboli during liver transplantation: incidence, risk factors, and management. Liver Transpl 2010;16: 1421-7. [3] Ozier Y, Klinck JR. Anesthetic management of hepatic transplantation. Curr Opin Anaesthesiol 2008;21:391-400. [4] Gwak MS, Kim JA, Kim GS, et al. Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients. Liver Transpl 2007;13:1451-4. [5] Burtenshaw AJ, Isaac JL. The role of trans-oesophageal echocardiography for perioperative cardiovascular monitoring during orthotopic liver transplantation. Liver Transpl 2006;12:1577-83. [6] Ellenberger C, Mentha G, Giostra E, Licker M. Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation. J Clin Anesth 2006;18:367-71. [7] Planinsic RM, Nicolau-Raducu R, Eghtesad B, Marcos A. Diagnosis and treatment of intracardiac thrombosis during orthotopic liver transplantation. Anesth Analg 2004;99:353-6. [8] Prah GN, Lisman SR, Maslow AD, Freeman RB, Rohrer RJ. Transesophageal echocardiography reveals an unusual cause of hemodynamic collapse during orthotopic liver transplantation–two case reports. Transplantation 1995;59:921-5. [9] Sibulesky L, Peiris P, Taner CB, Kramer DJ, Canabal JM, Nguyen JH. Intraoperative intracardiac thrombosis in a liver transplant patient. World J Hepatol 2010;2:198-200. [10] Costa MG, Chiarandini P, Della Rocca G. Hemodynamics during liver transplantation. Transplant Proc 2007;39:1871-3. [11] De Wolf A. Transesophageal echocardiography and orthotopic liver transplantation: general concepts. Liver Transpl Surg 1999;5: 339-40. [12] Hofer CK, Zollinger A, Rak M, et al. Therapeutic impact of intraoperative transoesophageal echocardiography during noncardiac surgery. Anaesthesia 2004;59:3-9. [13] Wax DB, Torres A, Scher C, Leibowitz AB. Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States. J Cardiothorac Vasc Anesth 2008;22: 811-3.