Division of Liver Transplant Anesthesiology, Department of Anesthesiology, Perioperative, and Pain Medicine Icahn School of Medicine at Mount Sinai Hospital New York New York USA Department of Anesthesiology Good Samaritan Hospital West Islip New York USA Department of Anesthesiology and Critical Care Medicine Memorial Sloan Kettering Cancer Center New York New York USA.
Liver Transpl. 2022 Oct;28(10):1603-1617. doi: 10.1002/lt.26489. Epub 2022 May 9.
This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016-2020) compared with the pre-TEE era (2011-2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End-Stage Liver Disease-sodium (MELD-Na) scores, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver-kidney transplantation. The patients with ICT were similar, except patients in the pre-TEE era had higher MELD-Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre-TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30-day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p = 0.002). The 30-day mortality rate was 36% (9/25) in the TEE era (p = 0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.
这项研究在单一中心，针对 9 年来肝移植过程中发生的与心内血栓（ICT）相关的发病率和结果进行了描述，该中心在常规使用经食管超声心动图（TEE）前后分别进行了研究。将 2011 年至 2020 年的成人肝移植患者根据常规 TEE 使用情况分为两个时期。通过查询麻醉记录中的搜索词来识别 ICT。描述性统计包括基线受者、供者、术中及术后特征的计数和比例。根据出院日期和死亡日期得出结果数据。与 TEE 前时期（2011-2015 年；25/685[3.7%]）相比，TEE 时期（2016-2020 年）ICT 的发生率更高（9/491[1.9%]；p<0.001）。患有 ICT 的患者 MELD-Na 评分、移植前住院、恶性肿瘤、药物性肝损伤、高血压、深静脉血栓形成、再灌注综合征、输注血小板和冷沉淀、使用止血药物的比例显著更高。ICT 组中更多患者同时接受了肝-肾移植。两组患者除 TEE 前时期患者的 MELD-Na 评分更高，丙型肝炎病毒感染率更高，肝性脑病发生率更低外，其余特征均相似。在 TEE 前时期，所有 ICT 均表现为术中心脏骤停，且 ICT 情况下的 30 天死亡率为 66.7%（9/9）。在 TEE 时期，80%的 ICT 是偶然诊断出的或归因于血流动力学不稳定（p=0.002）。TEE 时期的 30 天死亡率为 36%（9/25）（p=0.25）。TEE 时期 ICT 发病率增加，但死亡率更低，这表明常规术中 TEE 可能会在发生血流动力学崩溃之前，及早发现 ICT。
