Introduction: Thromboembolism is an uncommon complication of orthotopic liver transplantation (OLT), with effects ranging from asymptomatic to cardiac arrest. Hemodynamic instability can raise concern for thromboembolism, and intraoperative transesophageal echocardiogram (TEE) is indispensable for confirmation of an intracardiac thrombus. Case reports describe treatment with heparin, thrombolysis, or intraoperative suction catheter aspiration depending on severity.
Description: A 73-year-old male developed shock and cardiac arrest with pulseless electrical activity that occurred during OLT after reperfusion of the donor organ. TEE demonstrated a large right atrioventricular thrombus, with evidence of right ventricular (RV) failure and outflow obstruction. ROSC was rapidly achieved, but escalating doses of multiple vasoinotropes and inhaled nitric oxide were required to stabilize severe RV dysfunction. The thrombus was partially aspirated via the hepatic vein via the surgical field. Ultra-low-dose alteplase (1 mg) was then given with remarkable improvement in intraoperative hemodynamics, though significant transfusion was required after. The transplant was completed successfully.
Discussion: When hemodynamic instability occurs during OLT, TEE is essential in evaluating common causes of hemodynamic instability e.g. hypovolemia, right or left ventricular dysfunction, severe vasoplegia, etc. The midesophageal 4-chamber and RV inflow/outflow views were used to establish this diagnosis, and these views from this case and others will be reviewed and annotated. Given the intraoperative setting, there is not a suitable alternative to TEE for confidently establishing this diagnosis, and even a pulmonary artery catheter does not provide a similar degree of confidence without considerable diagnostic ambiguity. TEE use during OLT anesthesia can be analogized to rescue TEE in general, where a minimal number of TEE views prove the necessary information to rapidly and systematically establish a working diagnosis in undifferentiated shock or cardiac arrest.
