Cardiopulmonary Thromboembolism as an Unusual Cause of Death During Orthotopic Liver Transplantation
R. Renard Sessions, MD, J. A. Cohen, MD
Dept of Anesthesiology, University of Florida
Introduction: Orthotopic liver transplantation (OLT) has
developed into a procedure that is as frequent as other major
abdominal operations at experienced institutions. However, the
risk of perioperative mortality is still relatively high
(approximately 5%) for these patients. We present an unusual
cause of intraoperative mortality in a patient undergoing OLT.
Case Presentation: A 39 year old man presented for OLT. His
previous history included significant hepatitis C, cirrhosis,
encephalopathy, motor vehicle accident with 67% TBSA burns 16 yr
previously, chronic low back pain, upper GI bleed 10 months
previously, and gastroparesis. During the patient’s admission 1
mo previously, he was treated for encephalopathy and pneumonia.
On the night prior to OLT, he denied any chest pain or dyspnea
and related an exercise tolerance of approximately 4 METs. On
examination: he weighed 92 kg, was normotensive and slightly
tachycardic at 105 bpm. His chest was clear to auscultation and
no cardiac murmurs were detected. Laboratory examination showed
a normal BUN/Cr ratio, Hct of 27%, alkaline phosphatase was 320,
AST was 142, ALT was 70, albumin was 2.6, total protein was 8.2
and PT/PTT was normal.
After general anesthesia was induced and immediately after
incision, the surgical team noted a dense fibrous capsule
surrounding the liver and adjacent bowel that increased the
technical difficulty of the procedure. During the final stages
of removal of the native liver the patient suffered a period of
hemodynamic collapse as evidenced by a BP of 54/32, increased PA
pressure of 40/20, and decreased end-tidal CO2 of 12. A
transesophageal echocardiogram (TEE) demonstrated air entrained
in both the right and left heart. The surgeons found and
occluded an open hepatic vein containing air in the posterior
portion of the fibrous capsule that lead to resolution of
pulmonary hypertension and hemodynamic stability. During the
remainder of the procedure the patient was relatively stable
despite ongoing diffuse oozing at the time of closure. The
patient received 16 L of crystalloid, 800 cc of 5% albumin, 16 U
of PRBC, 10 U of FFP, 10 U of platelets and 8 U of
cryoprecipitate. Estimated blood loss was 11 liters.
During the patient’s 5 hr stay in the ICU, he continued to ooze.
Coagulation studies did not improve despite multiple attempts to
correct with FFP and platelets. Amicar (2 g administered in
divided doses) was given after multiple thromboelastograms
demonstrated massive fibrinolysis. Emergent reexploration was
performed in the operating room after his drains abruptly filled
with large quantities of blood. On arrival in the OR, his PA
pressures (65/52) were greater than systemic (48/38). He
stabilized somewhat with the addition of more blood products and
epinephrine at 0.06 µg/kg/min. Amicar, 2 g, was again given to
help correct persistent fibrinolysis as evidenced by TEG. TEE
was performed to evaluated cardiac function and during placement
of the probe BP, PAP, EtCO2, and HR decreased rapidly to
asystole. Chest compressions were begun. Massive clot was
observed in the right atrium, ventricle, and pulmonary arteries
by TEE. The patient was pronounced dead shortly thereafter. At
autopsy, new clot was demonstrated in the above locations with a
small-organized clot in the pulmonary artery. The patient was
also found to have diffuse Histoplasmosis pneumonia with abscess
formation and severe three-vessel coronary artery disease.
Discussion: This patient had multiple comorbid conditions that
compromised his chances of surviving an OLT. However, the
ultimate cause of death is most directly related to his
coagulopathy. He died from a clot that either formed in or
embolized to his right heart and pulmonary artery. Of concern is
the potential that the use of an antifibrinolytic agent (Amicar)
may accelerate occult thrombosis and, thereby, causing or
exacerbating embolic events, while still not controlling
fibrinolysis. Caution in the use of this product is therefore
indicated, although an exact protocol for its use during OLT is
not defined.
