Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824

Contents lists available at ScienceDirect

Journal of Cardiothoracic and Vascular Anesthesia

journal homepage: www.jcvaonline.com

Review Article

A Comprehensive Review of Transesophageal

Echocardiography During Orthotopic Liver
Transplantation
Adam A. Dalia, MD, MBAn,1, Antolin Flores, MD†,
Hovig Chitilian, MDn, Michael G. Fitzsimons, MDn
n
Department of Anesthesiology, Pain Medicine, and Critical Care, Massachusetts General Hospital, Harvard
Medical School, Boston, MA
†
Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH

Orthotopic liver transplantation (OLT) is characterized by significant hemodynamic disturbances and anesthetic challenges. Intraoperative
transesophageal echocardiography (TEE) can be used to guide management during these procedures. This review examines the role of
echocardiography during OLT, presents common TEE findings during each phase of OLT, and discusses the benefits demonstrated with TEE use
and the safety of TEE in this patient population. Finally, the authors propose an algorithm for the safe use of TEE during OLT.
& 2018 Elsevier Inc. All rights reserved.

Key Words: transesophageal echocardiography; echocardiography; orthotopic liver transplantation; intracardiac thrombus; transesophageal echocardiography
certification; transplantation anesthesiology; transesophageal echocardiography monitoring; intraprocedural transesophageal echocardiography guidance

PATIENTS PRESENTING FOR orthotopic liver transplanta- Association for the Study of Liver Diseases states that TEE should
tion (OLT) can be difficult to manage due to preoperative medical be used for all OLT procedures to assess intracardiac chamber
comorbidities, significant intraoperative hemodynamic shifts, and sizes, ventricular hypertrophy, systolic function, diastolic function,
periodic unexpected findings such as intracardiac thrombi or valvular function, and left ventricle outflow tract obstruction
pulmonary emboli.1–3 Transesophageal echocardiography (TEE) (LVOTO).6 As such, many anesthesiologists have advocated for
allows for real-time, continuous, intraoperative monitoring of the routine use of TEE in all liver transplantation surgeries.7 In
cardiac structures and function and is recommended during this study, the authors review the current literature regarding the
high-risk surgical procedures.4 According to the American Society utility, safety, and logistics of TEE during OLT and highlight the
of Echocardiography (ASE)/Society of Cardiovascular Anesthe- evidence gaps pertaining to 3-dimensional (3D) TEE, diastolic
siologists (SCA) Practice Guidelines for Transesophageal Echo- evaluation, and the role of transthoracic echocardiography (TTE)
cardiography, TEE may be a beneficial adjunct in noncardiac during liver transplantation.
surgical procedures during which there may be severe hemody-
namic compromise or when unexplained life-threatening circula- Methods
tory instability persists despite corrective therapy.5 The American
1 Published English language studies, practice guidelines, and
Address reprint requests to Adam A. Dalia, MD, MBA, Department of
Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital,
review articles from 2000 to 2017 were collected using
Harvard Medical School, 55 Fruit St., Boston, MA 02114. PubMed, Google Scholar, the Harvard Medical School Count-
E-mail address: [email protected] (A.A. Dalia). way Library, and the Massachusetts General Hospital

https://doi.org/10.1053/j.jvca.2018.02.033
1053-0770/& 2018 Elsevier Inc. All rights reserved.
1816 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824

Treadwell Library. Key words used in the search included volume liver transplantation centers regarding intraoperative
“intraoperative TEE,” “orthotopic liver transplantation,” “safety TEE use, and 13% of respondents reported TEE use in most or
of TEE,” “anesthetic complications during OLT,” “TEE find- all liver transplantations; these results were similar to those in
ings during OLT,” and “transthoracic echocardiography use a survey published 5 years prior that indicated routine TEE use
during OLT.” in 14.3% of all liver transplantations.13,14 The comprehensive-
A review of this literature was performed with the goal of ness of the echocardiographic examination performed during
determining the following: transplantation was variable. A limited examination was
performed by 73% of anesthesiologists, whereas 27% of
 Value of TEE during liver transplantation anesthesiologists performed a comprehensive examination as
 Prevalence of TEE use during liver transplantation defined by the ASE and SCA guidelines.13 The different
 Level of training held by individuals performing TEE degrees of examination completeness in this study may reflect
during liver transplantation the level of TEE training. Only 12% of responding anesthe-
 Safety of TEE during liver transplantation siologists were certified as diplomats of the National Board of
 TEE findings specific to liver transplantation Echocardiography (NBE) and had gained TEE competency
 Limitations of TEE during liver transplantation through practicing cardiac anesthesia or completing a cardiac
 Role of transthoracic echocardiography during liver fellowship. The majority (89%) had gained competency
transplantation through self-directed learning or continuing medical education
 Future of TEE in liver transplantation courses.
The most recent survey to date reported the findings of 79
Utility of TEE high-volume liver transplantation centers, performing at least
50 OLT cases a year, which represents 83% of all OLTs
Each phase (pre-anhepatic, anhepatic, and neohepatic) in a performed in the United States.15 The overall intraoperative
liver transplantation is associated with specific anesthetic TEE usage rate was 94.9% during liver transplantation.
management challenges that may benefit from the use of Specifically, 38% of respondents reported using TEE routinely
TEE.8 In 2010 the American Society of Anesthesiologists in all OLTs and 57% used TEE for “special circumstances” or
(ASA) and the SCA published survey results regarding TEE under “rescue conditions.” In the survey, 25.9% of anesthe-
use during OLT. More than half (53.7%) of expert consultants siologists performing TEE either were diplomats of the NBE
and 46% of ASA members agreed that TEE should be used in advanced perioperative TEE or had achieved testamur status
routinely for monitoring during OLT.7 In addition, the ASA, in advanced perioperative TEE, whereas 5.7% either were
SCA, ASE, and European Association of Echocardiography all diplomats or had achieved testamur status of basic TEE as
individually have recommended the use of TEE monitoring outlined by the NBE.15 Of the 598 responding anesthesiolo-
during OLT.9 The use of intraoperative TEE monitoring during gists, 28.4% regularly practiced cardiac anesthesia. There was
OLT has been shown to improve volume status monitoring and no difference in utilization rates between high- and low-
patient resuscitation, both which are crucial to patient survival volume centers and no statistical difference among academic,
during OLT.10 A single-center series of 100 OLT cases affiliate, or private practice institutional usage.15 The belief
performed with intraoperative TEE monitoring reported that that TEE was “not necessary” and lack of training in TEE were
the majority of patients (64%) required a management change the most commonly cited reasons by programs that did not use
due to findings on TEE.11 A separate single-center case series TEE on a routine basis. Per the surveys discussed, there is no
published in 2015 reported that 88% of patients demonstrated at uniformity across institutions with regard to the required
least 1 abnormal intraoperative TEE finding.12 Shillcut et al. certification level needed to perform TEE for liver
reported that the 10 most common findings during all phases of transplantation.
OLT included microemboli, right ventricular dysfunction,
thromboemboli, left-to-right flow through the patent foramen Safety Considerations of TEE During Liver
ovale, biventricular dysfunction, hyperdynamic ventricle, hypo- Transplantation
volemia, mildly reduced left ventricular function, left-to-right
flow through the patent foramen ovale, and left ventricular Kallmeyer et al. performed a retrospective review of
dysfunction.12 Given the available literature and societal guide- complications associated with TEE in 7,200 cardiac surgical
lines, it would be practical to consider the use of TEE for all patients.16 The overall complication rate was reported to be
liver transplantations. At the very least, the availability of TEE between 0.02% and 1%.16 Daniel et al. reviewed more than
for use in emergency situations such as unrelenting hypoten- 10,000 TEE examinations and confirmed similar results.17 The
sion, unexplained hypoxia, or malignant arrhythmias is crucial. reported frequency of TEE during liver transplantation is
increasing despite the debate on safety in the presence of
Prevalence of Use of TEE during OLT and Training esophageal varices, upper gastrointestinal (UGI) hemorrhage,
coagulopathy, and thrombocytopenia.18 Esophageal varices are
Recent surveys of liver transplantation centers have reported considered a relative contraindication to TEE placement, yet
the frequency of TEE use during liver transplantation as 73% of patients awaiting OLT have varices.19 Esophageal
between 87% and 94%.13,14 Wax et al. surveyed 40 high- injury and rupture of esophageal varices are among the highest
 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824 1817

concerns regarding TEE use during OLT.19–23 Spier et al. Table 2

reviewed 14 patients with grade 1 or 2 varices who underwent Esophageal Varices Grading29
intraoperative TEE during OLT.24 No complications or major Grading Description
bleeding were noted, although transgastric views were not
performed.24 A review by Pantham et al. of 24 patients with Grade 1 Small, straight varices that do not disappear with insufflation
grade 1 and 2 varices demonstrated no immediate bleeding Grade 2 Medium, tortious varices that occupy less than one third of the
esophageal lumen
complications from intraoperative TEE.25 Another retrospec- Grade 3 Large, coiled-shaped varices that occupy more than one third
tive chart review of 23 patients who underwent OLT with of the esophageal lumen
documented esophageal varices also found no complications
or major bleeding after TEE use.11 Markin et al. reviewed the
safety of TEE during OLT in 116 patients and reported a esophageal wall tension with these manuevers.30 Clamping
complication rate of 1.7%, with 1 patient who had undergone of the inferior vena cava (IVC) during the anhepatic phase of
esophageal banding the day before OLT experiencing a UGI OLT can cause an increase in hepatic venous pressure and
hemorrhage requiring balloon tamponade intraoperatively.26 result in engorgement of varices. The most likely cause of
A retrospective 10-year review of 232 liver transplantation variceal hemorrhage is increased variceal wall tension, which
patients who underwent intraoperative TEE monitoring was is determined primarily by hepatic venous portal gradient and
performed at the Mayo Clinic.27 Preoperative esophagogas- vessel diameter, and is exacerbated by intraoperative clamping
troduodenoscopy was performed in 230 patients, of whom of the hepatic vein.30,31 Manipulation of the probe should be
70% demonstrated varices; only 1 patient experienced a limited during the anhepatic phase for this reason.
variceal hemorrhage requiring banding from intraoperative Transgastric and deep transgastric views should be avoided
TEE. The largest case series to date examining the safety of in patients who are at high risk of esophageal injury (grade
TEE during liver transplantation in 287 patients with docu- 3 varices or history of UGI bleeding) because varices located
mented grade 1 or 2 esophageal varices reported only near the gastroesophageal junction tend to be the most super-
1 hemorrhagic event, a risk of 0.3%.28 These studies are ficial and vulnerable.31 Additional risks associated with
summarized in Table 1, and esophageal variceal grading intraoperative TEE use include dental injury, esophageal
definitions are presented in Table 2.29 perforation, Mallory-Weiss tear, odynophagia, oropharyngeal
Complications with TEE can occur during placement and injury, bacteremia, hematoma, endotracheal tube displacement,
manipulation of the probe while obtaining images. Proper and laryngeal palsy.20,32,33 Signs of esophageal injury should
lubrication and the use of a laryngoscope may minimize be monitored postoperatively and can include persistent sore
oropharyngeal trauma during placement.24 Methods suggested throat, dysphagia, or hematemesis.23
to reduce the risk of patient harm while performing TEE The safety of TEE in each patient presenting for liver
include reduction of the size of the probe, limiting advance- transplantation should be considered and discussed with
ment and manipulation of the probe in the esophagus, and members of the surgical and hepatology teams during the
reducing the length of time that the probe is in the patient.27 listing process. The algorithm discussed later in this article can
Some have suggested that the repeated anteflexion and retro- help guide the anesthesiologist when deciding whether to place
flexion of the probe can result in esophageal injury, although a TEE probe for monitoring (Fig 1). Based on the available
animal studies have not shown a significant increase in literature discussed in this review, it appears safe to place a

Table 1
Safety of Transesophageal Echocardiography for End-Stage Liver Disease Patients Undergoing Orthotopic Liver Transplantation

Study Authors Year Published Patients Included Patients with Notes

Complications

Suriani et al.11 1996 23 (documented varices) 0 No bleeding episodes

Spier et al.24 2009 14 (documented grade 0 No bleeding episodes
1 or 2 varices)
Burger-Klepp et al.28 2012 287 (documented grade 1 Patient was treated successfully with intraoperative
1 or 2 varices) balloon tamponade
Pantham et al.25 2013 24 (documented grade 0 No bleeding episodes
1 or 2 varices)
Pai et al.27 2015 232 (230 had documented 1 Variceal bleeding that was treated successfully with
grade 1, 2, or 3 varices) intraoperative banding
Markin et al.26 2015 116 (42 had history of 1 minor complication Minor complication was blood-tinged TEE probe
UGI bleeding) 1 major complication Major complication was UGI bleed in a patient who had
sclerotherapy the day before OLT; patient was treated
successfully with blood transfusions and had no
further episodes of bleeding

Abbreviations: OLT, orthotopic liver transplantation; TEE, transesophageal echocardiography; UGI, upper gastrointestinal.
1818 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824

Fig 1. Transesophageal echocardiography/transthoracic echocardiography in last 6 months. LV, left ventricular; LVOTO, left ventricular outflow tract obstruction;
PFO, patent foramen ovale; RV, right ventricular; SAM, systolic anterior motion; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography;
UGI, upper gastrointestinal.

TEE in liver transplantation patients without grade 3 varices or for conditions that potentially may compromise the transplan-
an acute history of UGI bleeding. tation process. Elevated right ventricular systolic pressures on
TTE may indicate portopulmonary hypertension, which neces-
Preoperative Liver Transplantation Evaluation sitates further evaluation, including right heart catheteriza-
tion.38 A bubble study done with TTE visualization can
Patients presenting for liver transplantation may have unmask the appearance of agitated saline in the left side of
comorbidities related to their underlying liver disease. Com- the heart, which may herald hepatopulmonary syndrome or a
mon conditions in patients presenting for liver transplantation right-to-left intrapulmonary shunt.39 The definitive way to
who have cardiac manifestations include cirrhotic cardiomyo- distinguish an intracardiac from an intrapulmonary shunt is to
pathy, hemochromatosis, non-alcoholic fatty liver disease, observe microbubbles actively passing through an intra-atrial
Wilson’s disease, sarcoidosis, chronic alcoholism, and familial defect or through the pulmonary veins, which can be a difficult
amyloidosis.34 Up to 28% of patients presenting for liver process. The presence of a patent foramen ovale indicates the
transplantation have been reported to have valvular pathology, risk for right-to-left shunting, hypoxemia, and paradoxical
27% have coronary artery disease, and 10% have pulmonary embolization of air or debris. Several studies have shown
hypertension (Table 3).35,36 evidence of diastolic dysfunction during TTE in cirrhotic
The preoperative cardiac evaluation for patients who are patients presenting for liver transplantation.40 Regarding
under consideration for OLT can include dobutamine stress intraoperative ventricular filling pressures and volume mea-
echocardiography (DSE), stress myocardial perfusion imaging, surements, the presence of impaired ventricular relaxation
electrocardiogram analysis, cardiac computer tomography, (diastolic dysfunction) can lead to inaccurate measurements
TTE, and coronary angiography.36 DSE often is performed when gathered from invasive pulmonary artery catheters as
preoperatively to evaluate for the presence of coronary artery opposed to TEE.35 Yet, there remains major evidence gaps
disease and predict perioperative cardiac events. DSE also can
be used to assess for the risk for dynamic or latent LVOTO,
and systolic anterior motion (SAM) of the anterior mitral
leaflet.37 Results of the preoperative TTE should be reviewed

Table 3
Prevalence of Preoperative Cardiovascular Abnormalities35,36

Condition Prevalence

Coronary artery disease 18%-27%

Left ventricular hypertrophy 43%
Valvular pathology 27.5%
Hepatopulmonary syndrome 20%
Video S1. Transesophageal echocardiography of the left ventricle in the
Portopulmonary hypertension 10% transgastric short-axis midpapillary view displaying a hyperdynamic left
Inducible left ventricular outflow tract obstruction 43% ventricle. Video 1 Still. Transesophageal echocardiogram of the left ventricle
Patent foramen ovale 25% in the transgastric short-axis midpapillary view displaying a hyperdynamic left
Pulmonary edema 12%-56% ventricle. Asterisk on the left ventricle shows a nearly obliterated left
Pericardial effusions 63% ventricular cavity during systole. Supplementary material related to this article
can be found online at https://doi.org/10.1053/j.jvca.2018.02.033.
 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824 1819

Table 4
Potential Baseline Transesophageal Echocardiographic Findings6

Right ventricular dilation/dysfunction

Left ventricular dilation/dysfunction
Valvular regurgitation/stenosis
Patent foramen ovale
Pulmonary hypertension (elevated right ventricular systolic pressure)
Pericardial effusion with/without chamber compression
Pleural effusion
Left ventricular upper septal hypertrophy
Diastolic dysfunction

Video S2.Transesophageal echocardiography in the midesophageal bicaval

regarding the utility of diastolic evaluation during liver view showing a venovenous bypass cannula situated in the cavoatrial junction.
transplantation with TEE. Video 2 Still. Transesophageal echocardiogram in the midesophageal bicaval
view showing a venovenous bypass cannula situated in the cavoatrial junction
coming from the superior vena cava. LA, left atrium; LV, left ventricle.
Induction of Anesthesia and the Pre-Anhepatic Phase Supplementary material related to this article can be found online at https://doi.
org/10.1053/j.jvca.2018.02.033.

The dissection, or pre-anhepatic, phase is the period from

the induction of anesthesia until placement of the portal continuity equation and Doppler; however, such calculations
venous cross-clamp. Immediately after induction, a complete can be time consuming. Right ventricular function also can be
TEE evaluation is conducted to assess or confirm baseline assessed intraoperatively using fractional area change and
cardiac structure and function. tricuspid annular plane systolic excursion; however, referenced
Patients with end-stage liver disease often are in a hyperdy- normal values are based on TTE studies. Lastly, identifying
namic state with an increased left ventricular ejection fraction patients who may be at high risk for LVOTO (small left
(Video 1) (Table 4).6 TEE often is used immediately after ventricle, upper septal hypertrophy, or SAM of the mitral
induction of anesthesia to confirm wire placement during valve) will better prepare the anesthesiologist for possible
central venous catheterization and to guide placement of the hemodynamic protuberances during the reperfusion phase.
cannula for venovenous bypass (Video 2). Pericardial or
pleural effusions may be present and in the event of Anhepatic Phase
cardiorespiratory compromise can be drained surgically.
After incision, the pre-anhepatic phase can include altera- The anhepatic phase extends from portal venous cross-
tions in preload secondary to drainage of ascites, hemorrhage, clamp up to reperfusion of the donor liver. Venous return to
and caval compression (Video 3). Perforation of suprahepatic the heart often is impaired secondary to surgical cross-clamp
veins or transjugular intrahepatic portosystemic shunt during placement on the portal vein and the IVC. The partial cross-
dissection may result in air embolization.41 TEE allows for clamp, or “piggy back,” technique allows some venous return
nearly instantaneous assessment of fluid administration or to continue through the IVC, but the benefits are variable.
initiation of therapy with vasopressors during periods of Venovenous bypass drains blood from the lower body below
hypotension. Ejection fraction can be estimated reasonably the liver to the suprahepatic IVC. Hypotension during veno-
by individuals proficient in TEE; objective measures of venous bypass can be due to low systemic vascular resistance
function include the use of Simpson’s rule, fractional area
change, and fractional shortening. Although these measure-
ments have their own pitfalls, they can serve as an estimation
of ventricular function for intraoperative trending purposes.
This assessment can help distinguish systolic dysfunction and
the need for more inotropic support from an underfilled
ventricle requiring additional fluids or albumin (Video 4).
Cardiac output and stroke volume can be calculated using the

Table 5
Hemodynamic Changes During Liver Transplantation43

Dissection/Pre-Anhepatic Anhepatic Reperfusion

Preload Video S3. Transesophageal echocardiography in the transgastric short-axis

midpapillary view revealing extensive ascites. Video 3 Still. Transesophageal
Afterload echocardiogram in the transgastric short-axis midpapillary view revealing
extensive ascites, seen encircling the liver and heart. Left ventricle; RV, right
Cardiac output ventricle. Supplementary material related to this article can be found online at
https://doi.org/10.1053/j.jvca.2018.02.033.
1820 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824

Cardiogenic shock unresponsive to pharmacologic manage-

ment during liver transplantation or dual organ transplantation
may be due to pulmonary emboli air embolism, or myocardial
infarction. In these extreme instances, extracorporeal mem-
brane oxygenation can provide temporary hemodynamic or
pulmonary support. TEE can be used to guide correct wire
placement and positioning for arterial and venous cannulae.46–49
Intraoperative respiratory decompensation after massive blood
transfusions has been reported during liver transplantation. The
use of TEE in these scenarios can help with the differential
diagnosis of hypoxemia and to guide peripheral cannula
placement.50
Video S4. Transesophageal echocardiography of the right ventricle in the
midesophageal 4-chamber view showing a dysfunctional and dilated right
Acute right heart failure is characterized by right ventricular
ventricle. Video 4 Still. Transesophageal echocardiogram of the right ventricle dilation, new onset tricuspid regurgitation, and a leftward shift
in the midesophageal 4-chamber view showing a dysfunctional and dilated of the interatrial and interventricular septa. Right heart failure
right ventricle, which has a basal measurement of 4.55 cm, indicating dilation.
LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. may be a component of PRS but also may be an exacerbation
Supplementary material related to this article can be found online at https://doi. of preexisting dysfunction. TEE can be used to identify right
org/10.1053/j.jvca.2018.02.033. ventricular dysfunction, allowing for immediate corrective
action with inotropic agents (milrinone or epinephrine) or
or impaired pump flow, if adequate preload is demonstrated on inhaled pulmonary vasodilators (inhaled nitric oxide or
TEE. The anhepatic phase typically is the most hemodynami- epoprostenol).
cally stable portion of the procedure, but a single-center Due to stagnation of blood in the IVC during the anhepatic
retrospective review reported that 56% of patients demon- phase, thrombi may form embolize to the heart and lungs
strated abnormal TEE findings during this phase.12 Findings (Video 5). Direct visualization of thrombi using TEE allows
identified on TEE during this phase have included right for the immediate institution of supportive measures, including
ventricular dysfunction, hypovolemia, and biventricular dys- inotropic agents and the administration of thrombolytic agents
function.12 Pulmonary emboli and intracardiac thrombi also (tissue plasminogen activator) or anticoagulation with heparin
have been reported to be present during this phase.2,42 TEE is to attenuate the size and growth of the thrombi.51,52 Throm-
helpful for the prompt identification of these conditions and bolytic and anticoagulant therapy require a high level of
the institution of appropriate therapy before reperfusion. The suspicion or confirmation on TEE imaging because adminis-
hemodynamic shifts expected at the various stages of liver tration of such therapies can result in life-threatening hemor-
transplantation are presented in Table 5.43 rhage. Case reports have described catheter-directed
thrombolytic therapy performed under TEE guidance for the
Reperfusion and the Neohepatic Phase management of intraoperative intracardiac thrombus, lending
further credence to TEE use or availability in this emergency
Reperfusion occurs after the completion of the portal situation.53 Echocardiography is instrumental for the diagnosis
anastomosis and unclamping of the portal vein and often is of intracardiac thrombi (ICT), aiding the navigation of
characterized by hemodynamic lability. Hypotension occurring
immediately after reperfusion typically is attributed to the
sudden delivery of hypothermic, acidotic, hyperkalemic blood
containing vasodilatory and inflammatory mediators.43 A
common hemodynamic dilemma encountered during reperfu-
sion has been termed postreperfusion syndrome, or PRS. This
syndrome can be characterized as a decrease in blood 4 30%
for at least 1 minute occurring within 5 minutes of reperfusion,
bradycardia, and increased pulmonary vascular resistance;
increased pulmonary artery pressure occurs in 12% to 77%
of patients.44 Reported risk factors for PRS include the age of
the donor, cold ischemic time, potassium levels, calcium
levels, Model for End-Stage Liver Disease score, and ane-
mia.44 If PRS results in intraoperative cardiac arrest, the
Video S5. Transesophageal echocardiography in the midesophageal 4-chamber
recommended treatment algorithm from the University of
view revealing diffuse intracardiac thrombi in all intracardiac chambers. Video
Pennsylvania involves correcting metabolic disturbances, 5 Still. Transesophageal echocardiogram in the midesophageal 4-chamber
standard cardiopulmonary resuscitation measures per the view revealing diffuse intracardiac thrombi in all intracardiac chambers
(asterisk) on both the right and left side of the heart. LA, left atrium; LV,
American Heart Association, direct surgeon mediated cardiac left ventricle; RA, right atrium; RV, right ventricle.Supplementary material
massage, followed by initiation of cardiopulmonary bypass if related to this article can be found online at https://doi.org/10.1053/j.jvca.2018.
no improvement is observed after 10 minutes of treatment.45 02.033.
 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824 1821

thrombectomy catheters and facilitating the monitoring of the norepinephrine; resolution typically can take days to
ICT after thrombolytic therapy. Although the etiology of ICT weeks.65,67
is unknown, risk factors have been identified and include Additional pathologies identified in the reperfusion phase
hypercoagulability in the presence of end-stage liver disease, include pericardial tamponade, pleural effusions, new onset
antifibrinolytic use, intraoperative endothelial injury, periods severe tricuspid regurgitation, and ventricular arrhythmias.69
of low blood flow as seen during caval clamping, or impaired Identifying these pathologies during the intraoperative period
myocardial function.54 In the largest single-center series of 495 also can guide postoperative management because those with
patients over a 3-year period, the incidence of PE or ICT biventricular dysfunction postreperfusion are 5 times more
during OLT was found to be 4%.55 Smaller case series have likely to die.12
reported an incidence of ICT ranging from 1.2% to 6.2%, with
mortality rates approaching almost 50%.56,57 Assessment of the Newly Implanted Liver
The presence of an intracardiac defect may allow a right-to-
left shunt of blood or clot to the systemic circulation. Air entry The neohepatic phase occurs after reperfusion during which
into the left atrium and ventricle can migrate to the right time surgeons and anesthesiologists are dealing primarily with
coronary artery and can lead to obstruction of coronary blood hemostasis and managing the complications of reperfusion.
flow and coronary spasm, resulting in inferior wall hypokin- TEE may be used to assess hepatic venous drainage and the
esis.58 Myocardial stunning can lead to hypotension or even integrity of portal venous anastomosis (Video 6). Turbulent
cardiogenic shock after the cold, hyperkalemic, acidic pre- flow or high velocities through these vessels may lead to graft
servative solution reaches the heart.54 Migration of clot or air dysfunction and can be detected on TEE.70 Currently there is
to the cerebral circulation may cause neurologic compromise; no standard cutoff for maximum or mean velocity of blood
the presence of air seen on TEE in the left ventricle should flow through these vessels, measured by Doppler frequency
prompt Trendelenburg positioning and pharmacologic support changes. Bjerke et al. described a case of using TEE
of circulation. visualization of the donor and recipient IVC after anastomosis;
Patients with unfavorable cardiac anatomy identified on the surpahepatic IVC demonstrated high turbulent flows
echocardiography are susceptible to LVOTO and SAM of the entering the right atrium.70 This finding led to the surgical
mitral valve leaflet. Hypovolemia, septal hypertrophy, existing correction of the anastomosis because there was a mechani-
SAM, and tachycardia may predispose patients to LVOTO and cally obstructed vessel underneath the liver. Color-flow
SAM. Some may exhibit findings of dynamic LVOTO during Doppler analysis after surgical intervention revealed a decrease
the preoperative DSE workup. However, this cannot always be in turbulent flow. TEE can play a pivotal role in post-
relied on because it is estimated that nearly one third of transplantation organ evaluation, and future investigations
patients do not reach the testing threshold of 4 85% of can help establish acceptable standard cutoffs for Doppler
maximum predicted heart rate that allows for a complete and evaluation of newly anastomosed vessels to help reduce early
accurate assessment with DSE.59,60 A case report by Essandoh graft dysfunction.
et al. highlights the utility of intraoperative TEE for diagnosing
dynamic LVOTO during reperfusion and the importance of Limitations
rapidly treating this pathology with immediate reduction in
myocardial contractility, volume resuscitation, and increasing There are specific limitations to TEE monitoring during the
afterload.61 To the contrary, if LVOTO occurs due to an perioperative period of liver transplantation. TEE generally is
underfilled left ventricle from a failing right ventricle, then
treatment would focus on right ventricular support to promote
forward flow to the left side of heart.
Takotsubo cardiomyopathy has been reported during liver
reperfusion and postoperatively.62–68 Takotsubo cardiomyo-
pathy is rare during liver transplantation, with a reported
incidence of 1.4%.67 There are no identified intraoperative risk
factors to determine patients more likely to develop takotsubo
cardiomyopathy per a recent study by Aniskevich et al.66 The
etiology of takotsubo cardiomyopathy is not defined clearly.
Some hypothesize that it occurs due to coronary artery
vasospasm and rapid release of catecholamines, which lead
to left ventricular apical ballooning as visualized on echocar-
diography.67 This ventricular wall dysfunction, apical balloon- Video S6.Transesophageal echocardiography in the lower esophageal position
displaying turbulent flow in the suprahepatic vena cava anastomosis. Video
ing, does not correlate to a singular coronary artery 6 Still. Transesophageal echocardiogram in the lower esophageal position
distribution, which can aide in differentiating takotsubo displaying turbulent flow in the suprahepatic vena cava anastomosis. Donor
cardiomyopathy from a coronary ischemic event.67 Treatment and recipient inferior vena cava flow is shown transitioning from laminar to
turbulent flow at the area of anastomosis. IVC, inferior vena cava. Supple-
consists of supportive measures with withdrawal of catecho- mentary material related to this article can be found online at https://doi.org/10.
lamine-inducing drugs such as epinephrine, ephedrine, and 1053/j.jvca.2018.02.033.
1822 A.A. Dalia et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 1815–1824

discontinued in the operating room; however, disposable outcomes for patients undergoing liver transplantation with
hemodynamic probes are available but require the intensivist TEE monitoring.
be familiar with TEE. High-volume liver transplantation
centers that also care for cardiac surgical patients may not Conclusion
have enough equipment to provide consistent use during liver
transplantation. In addition, institution-specific logistics (eg,
The variety of cardiopulmonary pathologies encountered by
location of TEE probes and machines, servicing probes and an anesthesiologist during liver transplantation make the use of
machines, available echocardiographers) have been described TEE for intraoperative monitoring reasonable. Major evidence
as factors that prohibits more frequent use of intraoperative
gaps regarding the use of TEE in liver transplantation still exist,
TEE during OLT.15 but scenarios such as persistent unexplained hypotension,
increasing pulmonary artery or right-sided filling pressures,
Role of TTE During Liver Transplantation
unexpected or severe reductions in cardiac output, or abrupt and
sustained changes in hemodynamic variables during any phase
TTE offers a noninvasive alternative method to monitor of an OLT may benefit from immediate TEE evaluation. As
cardiac function during liver transplantation. There is a paucity
such, routine use of TEE during liver transplantation should be
of peer-reviewed publications regarding the use of TTE during advocated. The collective consensus from the available literature
liver transplantation. Some possible reasons for this include the agrees that TEE can be performed safely in patients with
training necessary to be competent in obtaining adequate TTE
documented grade 1 or 2 esophageal varices and no recent
images, the need to find the “window” (ribspace) each time the history of acute UGI bleed. It is evident that TEE use during
practitioner desires to examine the heart, and the limited OLT is becoming more prevalent and likely will continue to
“windows” available to examine the heart with TTE during
increase as more anesthesiologists are trained in some capacity
liver transplantation. It is not feasible to use the subcostal with TEE.
“window” and parasternal window for imaging due to the nature
of the procedure. TTE remains the mainstay of preoperative
cardiopulmonary assessment for the OLT patient. Konerman Appendix A. Supplementary Material
et al reported an increased 6-month mortality in OLT patients
who demonstrated an inadequate assessment of the right Supplementary data associated with this article can be
ventricle via TTE.71 Similar studies have demonstrated the found in the online version at https://doi.org/10.1053/j.jvca.
ability of TTE findings to predict morbidity after liver trans- 2018.02.33.
plantation.72 At this point the role of TTE during OLT persists
as an alternative rather than a replacement to TEE and is mainly
available for use in patients deemed too high risk for TEE probe
placement (grade 3 varices or recent UGI bleeding). References

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