Peiris Prith, Pai Sher-Lu, Aniskevich Stephen, Crawford Claudia C, Torp Klaus D, Ladlie Beth L, Shine Timothy S, Taner C Burcin, Nguyen Justin H
Department of Anesthesiology, Mayo Clinic, Jacksonville, FL.
Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL.
Liver Transpl. 2015 Oct;21(10):1280-5. doi: 10.1002/lt.24161.
Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right- and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.
原位肝移植（OLT）期间的心内血栓形成（ICT）是一种罕见事件。然而，一旦发生，它是一种具有高死亡率的毁灭性并发症。本研究旨在确定OLT期间ICT可能的诱发因素。我们回顾性地确定了1998年至2014年在我们机构接受OLT的所有ICT患者的病例。在2750例OLT手术中，有10例患者术中发生ICT。回顾了患者血栓形成前即刻的术中血流动力学和凝血值以及血栓弹力图（TEG）数据。部分患者存在既往静脉血栓形成、心房颤动以及先前因门静脉高压放置经颈静脉肝内门体分流术，这些可能与OLT期间的ICT有关。终末期肝病模型评分高、心输出量低和脓毒症似乎与ICT无关。一些患者在未使用抗纤溶药物的情况下发生了ICT。TEG和凝血参数似乎无助于预测ICT的发生。4例患者左右心腔均发生ICT；这4例患者均未存活。仅右侧有血栓的6例患者全部存活。在存活的患者中，即使未使用溶栓药物，经食管超声心动图（TEE）显示随着时间推移血流动力学改善且血栓消失。这是由于内源性溶栓还是远端血栓蔓延至肺血管系统，抑或是两者皆有，尚不清楚。组织纤溶酶原激活剂可能在复苏过程中发挥作用。总之，若在OLT期间不常规使用TEE，ICT的发生率仍将是一个未被充分认识的事件。
