Sasaki Kengo, Tokodai Kazuaki, Fujio Atsushi, Miyagi Shigehito, Unno Michiaki, Kamei Takashi
Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan.
Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan.
Int J Surg Case Rep. 2021 Nov;88:106569. doi: 10.1016/j.ijscr.2021.106569. Epub 2021 Nov 4.
Patients with end-stage liver disease often have cardiac dysfunction, which can be worsened by hemodynamic instability in liver transplantation, causing congestive graft injury.
A 28-year-old male with Wilson's disease underwent liver transplantation. The patient's history included cirrhotic cardiomyopathy and a preoperative ejection fraction of 37% on echocardiography. After liver transplantation, massive transfusion and acute renal failure led to increased central venous pressure. Doppler ultrasonography (US) showed an increase in positive components of the hepatic vein triphasic wave, followed by pulsatile changes in the portal vein waveforms and an eventual to-and-fro pattern. Laboratory data showed severe elevations of hepatocellular transaminase levels. Based on Doppler US findings, we determined liver damage was due to passive congestion caused by heart failure. Immediate initiation of continuous hemodiafiltration (CHDF) and intra-aortic balloon pumping (IABP) led to the patient's recovery from severe heart failure and graft injury.
In our case, changes in the hepatic and portal vein waveforms and marked elevation of hepatocellular transaminases implied exacerbation of heart failure caused by hepatic congestion and injury. Worsening heart failure, in turn, led to progressive liver damage as the result of hepatic passive congestion. The patient's condition was successfully managed with early initiation of CHDF and IABP.
Doppler US can help diagnose congestive graft injury due to heart failure in liver transplant patients and should be performed during post-transplant management of patients with cardiac dysfunction.
终末期肝病患者常伴有心脏功能障碍，肝移植时的血流动力学不稳定会使其恶化，导致移植肝充血性损伤。
一名28岁患有威尔逊病的男性接受了肝移植。患者病史包括肝硬化性心肌病，术前超声心动图显示射血分数为37%。肝移植后，大量输血和急性肾衰竭导致中心静脉压升高。多普勒超声检查显示肝静脉三相波的正向成分增加，随后门静脉波形出现搏动性变化，最终呈往返模式。实验室数据显示肝细胞转氨酶水平严重升高。根据多普勒超声检查结果，我们确定肝损伤是由心力衰竭引起的被动性充血所致。立即开始持续血液透析滤过（CHDF）和主动脉内球囊反搏（IABP），使患者从严重心力衰竭和移植肝损伤中恢复。
在我们的病例中，肝静脉和门静脉波形的变化以及肝细胞转氨酶的显著升高提示肝充血和损伤导致心力衰竭加重。而心力衰竭的加重又因肝被动性充血导致肝损伤进展。通过早期开始CHDF和IABP成功地控制了患者的病情。
多普勒超声有助于诊断肝移植患者因心力衰竭导致的移植肝充血性损伤，对于心脏功能障碍患者的移植后管理应进行此项检查。
