Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI.
Departments of Surgery, Transplantation Division, University of Wisconsin Hospital, Madison, WI.
Liver Transpl. 2019 Nov;25(11):1682-1689. doi: 10.1002/lt.25498. Epub 2019 Jun 25.
Intracardiac thrombus (ICT) is an intraoperative complication with high mortality that occurs during orthotopic liver transplantation (OLT). Patients with end-stage liver disease have compromised coagulation pathways, and when combined with stressors of surgery, thrombi can form. However, it is unknown which patients are most likely to develop ICT. We performed a retrospective cohort study of all OLT patients at our hospital from 2010 to 2017 to identify risk factors for ICT. An analysis was performed with conventional bivariate tests and logistic regression. The incidence of ICT during OLT was 4.2% (22/528) with a 45.5% (10/22) mortality. Patients who developed ICT had higher physiologic Model for End-Stage Liver Disease scores at the time of transplant (25.1 versus 32.4; P = 0.004), received grafts from donors with a higher body mass index (28.1 versus 32.2 kg/m ; P = 0.007), and had longer intraoperative warm ischemia times (53.1 versus 67.5 minutes; P = 0.001). The odds of developing ICT were significantly lower after administration of intravenous (IV) heparin prior to inferior vena cava (IVC) clamping compared with no administration of heparin (odds ratio, 0.25; 95% confidence interval, 0.08-0.75; P = 0.01). In conclusion, the incidence of ICT at our institution is higher than previously reported, which may be explained by our routine use of transesophageal echocardiography. Although many factors associated with ICT in this study are nonmodifiable, administration of IV heparin prior to IVC cross-clamping is modifiable and was found to be protective. Further studies will be needed to confirm findings and ultimately aid in preventing these lethal events.
心内血栓（ICT）是原位肝移植（OLT）过程中一种死亡率很高的术中并发症。终末期肝病患者的凝血途径受损，加上手术的应激因素，可能会形成血栓。但是，尚不清楚哪些患者最有可能发生 ICT。我们对 2010 年至 2017 年我院所有接受 OLT 的患者进行了回顾性队列研究，以确定 ICT 的危险因素。采用常规双变量检验和逻辑回归进行分析。OLT 期间 ICT 的发生率为 4.2%（22/528），死亡率为 45.5%（10/22）。发生 ICT 的患者在移植时的生理模型终末期肝病评分更高（25.1 比 32.4；P=0.004），接受的供体移植物的体重指数更高（28.1 比 32.2kg/m2；P=0.007），术中热缺血时间更长（53.1 比 67.5 分钟；P = 0.001）。与未给予肝素相比，在腔静脉阻断前给予静脉（IV）肝素后发生 ICT 的可能性明显降低（比值比，0.25；95%置信区间，0.08-0.75；P = 0.01）。总之，本机构 ICT 的发生率高于之前的报道，这可能是由于我们常规使用经食管超声心动图。尽管本研究中与 ICT 相关的许多因素是不可改变的，但在腔静脉阻断前给予 IV 肝素是可改变的，并且被发现具有保护作用。需要进一步的研究来证实这些发现，并最终有助于预防这些致命事件。
