Department of Critical Care, The University of Melbourne, Melbourne, Australia.
Department of Anaesthesia, Austin Health, Melbourne, Australia.
PLoS One. 2022 Feb 4;17(2):e0263386. doi: 10.1371/journal.pone.0263386. eCollection 2022.
Despite increasing attention in the cardiac anesthesiology literature, continuous measurement of right ventricular pressure using a pulmonary artery catheter has not been described in orthotopic liver transplantation, despite similarities in the anesthetic approach to the two populations. We describe our preliminary experience with this technique in orthotopic liver transplantation, and by combining various derived measures with trans-esophageal echocardiography, make some early observations regarding the response of these measures of right ventricular function during the procedure.
In this case series, ten patients (five men and five women) undergoing orthotopic liver transplantation in our institution had their surgeries performed while monitored with a pulmonary artery catheter with continuous right ventricular port transduction and trans-esophageal echocardiography. We recorded various right ventricular waveform (early-to-end diastolic pressure difference, right ventricular outflow tract gradient, right ventricular dP/dT and right ventricular end-diastolic pressure) and echocardiographic (right ventricular fractional area change, tricuspid annular plane systolic excursion, right ventricular lateral wall strain) and described their change relative to baseline at timepoints five minutes before and after portal vein reperfusion, immediately after hepatic artery reperfusion and on abdominal closure.
Except for tricuspid annular plane systolic excursion at five minutes prior to reperfusion (mean -0.8 cm; 95% CI-1.4, -0.3; p = 0.007), no echocardiographic metric was statistically significantly different at any timepoint relative to baseline. In contrast, changes in right ventricular outflow tract gradient and right ventricular dP/dt were highly significant at multiple timepoints, generally peaking immediately before or after reperfusion before reducing, but not returning to baseline in the neohepatic phase. Nine of 10 participants in this series demonstrated a degree of dynamic right ventricular outflow tract obstruction, which met criteria for hemodynamic significance (> 25 mmHg) in two participants. These changes were not materially affected by cardiac index.
Dynamic right ventricular outflow tract obstruction of varying severity appears common in patients undergoing orthotopic liver transplantation. These results are hypothesis generating and will form the basis of future prospective research.
尽管在心脏麻醉学文献中越来越受到关注，但在原位肝移植中，尽管两种人群的麻醉方法相似，但仍未描述使用肺动脉导管连续测量右心室压力。我们描述了我们在原位肝移植中使用该技术的初步经验，并通过将各种衍生测量值与经食管超声心动图相结合，对这些右心室功能测量值在手术过程中的反应进行了一些早期观察。
在本病例系列中，我们机构的 10 名患者（5 名男性和 5 名女性）在接受原位肝移植手术时，使用肺动脉导管进行监测，该导管具有连续的右心室端口转换和经食管超声心动图。我们记录了各种右心室波形（早期至舒张末期压力差、右心室流出道梯度、右心室 dp/dt 和右心室舒张末期压力）和超声心动图（右心室分数面积变化、三尖瓣环平面收缩期位移、右心室外侧壁应变），并描述了它们在门静脉再灌注前 5 分钟、肝动脉再灌注后即刻和腹部关闭时相对于基线的变化。
除了再灌注前 5 分钟的三尖瓣环平面收缩期位移（平均-0.8cm；95%CI-1.4，-0.3；p=0.007）外，没有任何超声心动图指标在任何时间点相对于基线有统计学差异。相比之下，右心室流出道梯度和右心室 dp/dt 的变化在多个时间点均具有显著意义，通常在再灌注前或后即刻达到高峰，然后在新肝期下降，但未恢复到基线。本系列研究中的 10 名参与者中有 9 名存在不同程度的动态右心室流出道梗阻，其中 2 名参与者的梗阻符合血流动力学意义（>25mmHg）标准。这些变化没有受到心指数的显著影响。
在接受原位肝移植的患者中，严重程度不同的动态右心室流出道梗阻似乎很常见。这些结果是假设性的，将为未来的前瞻性研究奠定基础。
