S011: INCIDENCE AND RISK FACTORS FOR INTRAOPERATIVE CARDIAC THROMBOTIC COMPLICATIONS IN LIVER TRANSPLANTATION: SINGLE CENTER RETROSPECTIVE STUDY
Marianfeli C Landino Delgado, MD; Mariana Acosta, MD; Nicolas Caram, MD; Daniel Schmidt, MD; Vadim Shatz, MD; Behrouz Ashrafi, MD; Yehuda Raveh, MD; Fouad Souki, MD, MS; Ramona Nicolau Raducu, MD, PhD
Jackson Memorial Hospital-University of Miami
Introduction: The occurrence of intracardiac thrombus (ICT) during liver transplantation (LT) is rare but can lead to severe complications. Reported incidence rates range from 0.36% to 6.25%1. ICT may cause hemodynamic instability, intraoperative cardiac arrest or death, with an associated mortality rate of 45%–68%2.
Method: We conducted a comprehensive review of 1060 liver transplant cases, focusing on the incidence of intracardiac thrombosis (ICT) and pulmonary embolism (PE) during LT surgery. Transesophageal echocardiography was used routinely in LT cases for direct visualization of ICT and diagnosing PE: (i) acute onset of systemic hypotension with sudden increase in central venous pressure from baseline and (ii) echocardiographic evidence for pulmonary artery clots, or acute right heart pressure overload (dilated right ventricle and atrium with emptied left ventricle). Logistic regression was performed to identify pre-transplant and intraoperative predictors statistically associated with intraoperative cardiac thrombosis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Kaplan-Meier log-rank curves were calculated for 1-year patient survival.
Results: The overall incidence of intraoperative cardiac thrombotic complications in our series was 4%. The cardiac event occurred 21% during dissection, 36% during anhepatic and 43% after portal reperfusion. Prophylactic heparin of 30 units/kg at the time of portal clamp was administered in 67% of the patients. A median dose of 5 g EACA was administrated only after reperfusion, in 25% of the patients and was not associated with any of the cardiac thrombosis. Significantly, less cardiac thrombotic complications occurred while heparin prophylaxis was given (2% vs 9% respectively, p<0.0001; OR 0.17 95%CI 0.087-0.330), see Figure 1. Clinically relevant factors from univariate analysis on group with and without cardiac thrombotic events were included as covariates to adjust for confounders: LT/LK, gender, MELD score, redo transplantation, PVT, pre-transplant hospitalization, heparin prophylactic, intraoperative RRT, massive transfusion>10 units pRBC, see Table 1. Logistic regression identified 3 risk factors associated with intraoperative cardiac thrombotic complications: massive transfusion > 10 units pRBCs; intraoperative RRT and when no prophylactic heparin was administrated. Under logistic regression the entirely model was significant (χ2 = 26.0; P < 0.0001), see Table 2. A C statistic of 0.85 was calculated for these risk factors. Kaplan Meier survival curve at 1 year shows a 77% survival rate, see Figure 2.
Conclusions: Our study underscores the critical role of prophylactic heparin in mitigating the risk of intraoperative cardiac thrombotic complications1,2. These complications are not only associated with intraoperative deaths and cardiac arrest but also have a severe impact on 1-year survival rate1,3.
