Transesophageal Echocardiography Use for Orthotopic Liver Transplant

Abstract

Impact Statement: Transesophageal echocardiography (TEE) is an invaluable tool used in cardiac surgery. So why is it not consistently used in other high-risk surgeries, such as orthotopic liver transplantation (OLT)?

Key Words: Transesophageal echocardiography, Liver graft, Liver transplantation

Introduction: This scholarly project observes a high-risk patient undergoing an OLT. Hemorrhage, acute cardiac dysfunction, fluid shifts, and other intraoperative pathologies associated with OLT present many challenges for the anesthesia provider. Therefore, timely identification, evaluation, and intervention of intraoperative pathology are necessary to maintain hemodynamic stability. Traditionally, intra-arterial and pulmonary artery catheters (PACs) were used as hemodynamic monitors. Recently, however, transesophageal echocardiography (TEE) has been used for noncardiac surgery to assess hemodynamic status. The objective of this project is to identify the benefits gained from using TEE during OLT in addition to traditional hemodynamic monitoring techniques (CVP/PAOP) and how these findings affect fluid and medication management.

Case Presentation: A 50-year-old female underwent general anesthesia for OLT. The patient’s medical history included cirrhosis, ascites, portal hypertension, portal vein thrombosis, thrombocytopenia, anemia, obesity, and coronary artery disease. Surgical history included splenic embolization and coronary artery bypass graft. The patient was transported to the OR, and standard monitors were applied. Initial VS were as follows: BP 148/75, HR 89, SpO₂ 92%, RR 24. The patient underwent an uneventful anesthetic induction and intubation. Sevoflurane was used to maintain anesthesia. A radial arterial line and an internal jugular introducer with a PAC were placed. Epinephrine and norepinephrine infusions were used to treat intraoperative hypotension. 1.5 L of 5% albumin, 6 U of packed red blood cells (PRBCs), 5 U of fresh frozen plasma (FFP), and 1 U of platelets were administered. Along with intraarterial blood pressure monitoring, CVP and PA pressure monitoring was used to estimate volume status and treat hypotension. Profound hypotension was treated frequently with vasopressors, fluids, and blood products throughout the case. The patient remained intubated and was transported to the intensive care unit (ICU) postoperatively. Forty-eight hours postoperatively, the patient remained intubated. Due to acute kidney injury, a continuous furosemide infusion and subsequent dialysis were required.

Discussion: The reviewed literature provided ample evidence that TEE for OLT can be used to make new intraoperative diagnoses, many of these being difficult to identify by other means. Common findings included intracardiac thrombus (ICT), ventricular dysfunction, and multiple embolic pathologies. Shillcutt et al found that 88% of participants in their study had some form of abnormal TEE finding during OLT. TEE findings were also found to impact fluid and medication administration. Hofer et al found that vasopressor (56%), vasodilator (63%), and fluid management (50%) were all impacted by TEE findings in OLT patients. While evidence was provided to exhibit the efficacy of TEE as an intraoperative monitor, sufficient evidence was not provided to support better patient outcomes based on TEE assessments. This is largely due to a lack of quality observations and controlled research during OLT. The most significant evidence supporting better outcomes was from a retrospective observational cohort study that compared TEE, PAC, and a combined therapy group. The authors found that the patients undergoing OLT with both TEE and PAC had the lowest hospital length of stay (LOS), 30-day mortality, and infusion of fluids. This suggests that the addition of TEE with traditional monitors may be the safest method of hemodynamic monitoring. In the presented case study, the addition of TEE monitoring may have helped diagnose the causes of hemodynamic instability more rapidly and potentially altered medication and fluid administration. While the assumption that timely diagnosis of intraoperative findings leads to better outcomes may be reasonable, higher-powered studies are necessary to verify this assumption. Until beneficial outcomes have been validated, the use of TEE cannot be recommended as a comprehensive intervention for every OLT. However, it should be used based on the anesthesia provider’s judgment along with other monitoring tools.

Conflict of Interest: I have no conflict of interest to disclose.

References:

1. De Marchi L, Wang CJ, Skubas NJ, et al. Safety and benefit of transesophageal echocardiography in liver transplant surgery: a position paper from the society for the advancement of transplant anesthesia (SATA). Liver transplant. 2020;26:1019-1029. doi: 10.1002/lt.25800


2. Hofer RE, Vogt MNP, Taner T, Findlay JY. Influence of intraoperative transesophageal echocardiography and pulmonary artery catheter monitoring on outcomes in liver transplantation. Transplant. Direct. 2020;6:e525-e525. doi: 10.1097/TXD.0000000000000972


3. Shillcutt, Sasha K., MD, FASE, Ringenberg KJ, MD, Chacon MM, MD, et al. Liver transplantation: intraoperative transesophageal echocardiography findings and relationship to major postoperative adverse cardiac events. J.Cardiothorac. Vasc. Anesth. 2016;30:107-114. https://doi-org.ezproxy.tcu.edu/10.1053/j.jvca.2015.09.009.


4. Fayad A, Shillcutt S, Meineri M, Ruddy TD, Ansari MT. Comparative effectiveness and harms of intraoperative transesophageal echocardiography in noncardiac surgery: a systematic review. Semin Cardiothorac Vasc Anesth.2018;22:122-136.

doi: 10.1177/1089253218756756

1. Hofer CK, Zollinger A, Rak M, et al. Therapeutic impact of intra-operative transoesophageal echocardiography during noncardiac surgery. Anaesthesia. 2004;59:3-9. https://doi-org.ezproxy.tcu.edu/10.1111/j.1365-2044.2004.03459.x.