Kyota Fukazawa

Rapid assessment and safe management of severe pulmonary hypertension with milrinone during orthotopic liver transplantation

Fukazawa K, Poliac LC, Pretto EA. Rapid assessment and safe management of severe pulmonary hypertension with milrinone during orthotopic liver transplantation.
Clin Transplant 2010: 24: 515–519.
© 2009 John Wiley & Sons A/S.

Long‐term deleterious effects of aortohepatic conduits in primary liver transplantation: Proceed with caution

Aortohepatic conduits provide a vital alternative for graft arterialization during liver transplantation. Conflicting results exist with respect to the rates of comorbidities, and long‐term survival data on primary grafts are lacking. To identify the complications associated with aortohepatic conduits in primary liver transplantation and their impact on survival, we conducted a single‐center, retrospective cohort analysis of all consecutive adult (n = 1379) and pediatric primary liver transplants (n = 188) from 1998 to 2009. The outcomes of aortohepatic conduits were compared to those of standard arterial revascularization. Adults with a conduit (n = 267) demonstrated, in comparison with adults with standard arterialization (n = 1112), an increased incidence of late (>1 month after transplantation) hepatic artery thrombosis (HAT; 4.1% versus 0.7%, P < 0.001) and ischemic cholangiopathy (7.5% versus 2.7%, P < 0.001) and a lower 5‐year graft survival rate (61% versus 70%, P = 0.01). The adjusted hazard ratio (HR) for graft loss in the conduit group was 1.38 [95% confidence interval (CI) = 1.03‐1.85, P = 0.03]. Notably, the use of conduits (HR = 4.91, 95% CI = 1.92‐12.58) and a warm ischemia time > 60 minutes (HR = 11.12, 95% CI = 3.06‐40.45) were independent risk factors for late HAT. Among children, the complication profiles were similar for the conduit group (n = 81) and the standard group (n = 107). In the pediatric cohort, although the 5‐year graft survival rate for the conduit group (69%) was significantly impaired in comparison with the rate for the standard group (81%, P = 0.03), the use of aortohepatic conduits did not emerge as an independent predictor of diminished graft survival via a multivariate analysis. In conclusion, in adult primary liver transplantation, the placement of an aortohepatic conduit should be strictly limited because of the greater complication rates (notably late HAT) and impaired graft survival; for children, its judicious use may be acceptable. Liver Transpl 19:916–925, 2013.

Determination of the safe range of graft size mismatch using body surface area index in deceased liver transplantation.

In live donor liver transplantation, rigorous standardized criteria for matching of liver volume between donor and recipient have prevented graft loss because of size mismatch. In deceased whole liver transplantation, the safe donor–recipient size mismatch range remains unknown. We developed a multivariate survival model (generalized additive model) to estimate hazard risk of body surface area index (BSAi) for 3‐year graft survival using data derived from the national registry database between 2005 and 2010. BSAi was calculated by BSA of donor divided by BSA of recipient. 24 509 patients were included in the analysis. Small‐for‐size (SFS) grafts with BSAi less than 0.78 had a significant impact on graft dysfunction with progressive increase of hazard risk toward the lowest end and a higher incidence of primary graft nonfunction and vascular thrombosis. Large‐for‐size (LFS) grafts with BSAi greater than 1.24 had a significant impact on graft dysfunction with progressive increase of hazard risk toward the largest end. Our findings suggest that donor grafts with BSAi < 0.78 could be considered ‘SFS’ and donor grafts with BSAi > 1.24 could be considered ‘LFS’, with both extremes resulting in decreased graft survival. Therefore, BSAi > 0.78 and <1.24 appears to be a safe range to avoid adverse outcome associated with size mismatch.

Coronary artery disease and its risk factors in patients presenting for liver transplantation

STUDY OBJECTIVE To determine the distribution of coronary artery disease (CAD) and its risk factors across the various etiologies of end-stage liver disease, and to elucidate the relationship between severe alcohol consumption and CAD. DESIGN Retrospective multicenter study analysis. SETTING National Standard Transplant Analysis and Research file data. MEASUREMENTS Data from all primary adult orthotopic liver transplant recipients during the period from 2004 through 2006 were studied. Data were divided into 5 groups according to each patients etiology of end-stage liver disease. The prevalence of CAD and the distribution of its risk factors were compared among groups. MAIN RESULTS 17,482 cases were studied. The incidence of CAD was highest in nonalcoholic hepatic steatosis (7.4%) and lowest in biliary cirrhosis (1.7%). No difference in prevalence of CAD and its risk factors was noted between the viral and alcoholic etiologies (Hepatitis C 2.7%, Hepatitis B 2.3%, and alcoholic cirrhosis 2.9%). CONCLUSIONS Prevalence of CAD and the distribution of CAD risk factors in patients with severe alcohol consumption were similar to patients with viral hepatitis. CAD was most prevalent in patients with hepatic steatosis. This study argues against the notion of decreased expression and progression of CAD in patients with alcoholic cirrhosis presenting for liver transplantation.

Is the immediate reversal of diastolic dysfunction of cirrhotic cardiomyopathy after liver transplantation a sign of the metabolic etiology

Cirrhotic cardiomyopathy currently is believed to be a multifactorial entity. This communication describes a case of immediate intraoperative recovery of diastolic function following liver transplantation. This suggests that an underlying metabolic inhibition of myocardial metabolism is an important factor in the development of cardiomyopathy in end‐stage liver disease. Liver Transpl 15:1417–1419, 2009.

Invasive Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus: Cardiac Anesthesia in Liver Transplant Settings

OBJECTIVES Resection of renal cell carcinomas (RCC) with tumor thrombus invasion into the inferior vena cava (IVC) is associated with significant perioperative morbidity and mortality. This study examined the intra- and inter-departmental collaboration among cardiac, liver transplantation, and urologic surgeons and anesthesiologists in caring for these patients. DESIGN After IRB approval, medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010 in this institution, were reviewed. Data were collected and analyzed by one way-ANOVA and chi-square test. SETTING Major academic institution, tertiary referral center. PARTICIPANTS This was a retrospective study based on the medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty-eight patients (82.9%) with level III thrombus and 12 patients (17.1%) with level IV thrombus were analyzed. Sixty-five (92.9%) did not require any extracorporeal circulatory support; 5 (2 with level III and 3 with level IV; 7.1%) required cardiopulmonary bypass. No patients required veno-venous bypass. Compared to patients with level III thrombus extension, patients with level IV had higher estimated blood loss (6978±2968 mL v 1540±206, p<0.001) and hospital stays (18.8±1.6 days v 8.1±0.7, p<0.001). Intraoperative transesophageal echocardiography (TEE) was utilized in 77.6% of patients with level III thrombus extension and in 100% of patients with level IV thrombus extension. Intraoperative TEE guidance resulted in a significant surgical plan modification in 3 cases (5.2%). Short-term mortality was low (n = 3, 4.3%). CONCLUSIONS Utilization of specialized liver transplantation and cardiac surgical techniques in the resection of RCC with extension into the IVC calls for a close intra-and interdepartmental collaboration between surgeons and anesthesiologists. The transabdominal approach to suprahepatic segments of the IVC allowed avoidance of extracorporeal circulatory support in most of these patients. Perioperative management of these patients reflected the critical importance of TEE-proficient practitioners experienced in liver transplantation and cardiac anesthesia.

Crystalloid flush with backward unclamping may decrease post-reperfusion cardiac arrest and improve short-term graft function when compared to portal blood flush with forward unclamping during liver transplantation.

During liver transplant (LT), the release of vasoactive substances into the systemic circulation is associated with severe hemodynamic instability that is injurious to the recipient and/or the post‐ischemic graft. Crystalloid flush with backward unclamping (CB) and portal blood flush with forward unclamping (PF) are two reperfusion methods to reduce reperfusion‐related cardiovascular perturbations in our center. The primary aim of this study was to compare these two methods. After institutional review board (IRB) approval, cadaveric whole LT cases performed between 2003 and 2008 were reviewed. Patients were divided into two groups based on reperfusion methods: CB or PF. After background matching with propensity score, the effect of each method on post‐operative graft function was assessed in detail. In our cohort of 478 patients, CB was used in 313 grafts and PF in 165. Thirty‐day graft survival was lower, and risk of retransplantation was higher in PF. Multivariable model showed that CB is an independent factor to reduce primary non‐function, cardiac arrest and improve 30‐d graft survival. Also, the incidence of ischemic‐type biliary lesions was significantly higher in the PF group. Reperfusion methods affect intraoperative hemodynamics and post‐transplant outcome. CB allows for control over temperature and composition of the perfusate, perfusion pressure, and the rate of infusion.

Peak Serum AST Is a Better Predictor of Acute Liver Graft Injury after Liver Transplantation When Adjusted for Donor/Recipient BSA Size Mismatch (ASTi)

Background. Despite the marked advances in the perioperative management of the liver transplant recipient, an assessment of clinically significant graft injury following preservation and reperfusion remains difficult. In this study, we hypothesized that size-adjusted AST could better approximate real AST values and consequently provide a better reflection of the extent of graft damage, with better sensitivity and specificity than current criteria. Methods. We reviewed data on 930 orthotopic liver transplant recipients. Size-adjusted AST (ASTi) was calculated by dividing peak AST by our previously reported index for donor-recipient size mismatch, the BSAi. The predictive value of ASTi of primary nonfunction (PNF) and graft survival was assessed by receiver operating characteristic curve, logistic regression, Kaplan-Meier survival, and Cox proportional hazard model. Results. Size-adjusted peak AST (ASTi) was significantly associated with subsequent occurrence of PNF and graft failure. In our study cohort, the prediction of PNF by the combination of ASTi and PT-INR had a higher sensitivity and specificity compared to current UNOS criteria. Conclusions. We conclude that size-adjusted AST (ASTi) is a simple, reproducible, and sensitive marker of clinically significant graft damage.

Internal jugular valve and central catheter placement.

A 27-YR-OLD male patient with a history of end-stage liver disease due to hepatitis C infection and a transjugular intrahepatic portosystemic shunt presented for orthotopic liver transplantation. We attempted to place a central venous pressure catheter via the right internal jugular vein (IJV), initially without ultrasound. An 18-gauge catheter was easily passed into the IJV using anatomic landmarks, but the guide wire could not be advanced more than 8 cm because of resistance. We then performed an ultrasound examination using a SonoSite TITAN (SonoSite Inc., Bothell, WA) and detected a large venous valve protruding into the lumen of the IJV (fig. 1). To avoid damage, we then switched sides and placed a left IJV catheter instead, which was performed successfully under ultrasound guidance. After verifying catheter placement with a portable chest x-ray film, we proceeded to orthotopic liver transplantation without further complications. We report a case of difficult central venous catheter placement in the presence of a large venous valve located in the right IJV. An IJV valve is present in 88–100% of cases, and its function is to prevent retrograde flow from the right atrium to the brain. The anatomic location of these valves is usually in the distal portion of the IJV, just proximal to the jugular bulb. Because the IJV valve is mostly located in the retroclavicular space, the ultrasound assessment of this valve is difficult with large ultrasound probes. In the majority of cases, the valve leaflet is bicuspid (77–98%), but tricuspid (0–7%) or unicuspid (1.4–16%) valves have been reported. Normally, valve cusps are thin (100 m) translucent structures surrounded by a thickened ridge of tissue in which cusps attach to the vein. Complete valve closure occurs during diastole when atrial contraction transmits pressure backward into the superior vena cava. When intrathoracic pressure is increased, as in this patient (ascites and positive pressure ventilation), competent IJV valves prevent excessive backward flow to the brain. IJV valves can be competent up to a static pressure of 100 mmHg, such as in cases of coughing or Valsalva maneuver. However, the large venous valve might cause protrusion of the valve cusp into the lumen under increased venous pressure. In this circumstance, the large venous valve could potentially cause difficult central catheter placement, and if multiple or forceful attempts to overcome resistance are performed, the possibility of damage exists. In this case, ultrasound examination and guidance allowed us to visualize the exact location of the IJV. As a result, the procedure was aborted before any damage was done.

Reversal of hypercoagulability with hydroxyethyl starch during transplantation: a case series

During transplant surgery, clot formation resulting in life-threatening thromboembolic phenomena or graft loss may be a consequence unless close monitoring of coagulation and anticoagulation treatment is instituted in a timely manner. Three cases with a hypercoagulable state, as determined by thrombelastography at the time of surgery, but whose hypercoagulation was gradually attenuated with hydroxyethyl starch infusion during transplantation, are presented.