Transoesophageal echocardiography during liver transplantation

Abstract

Liver transplantation (LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver transplant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the procedures as a result of both the disease process and the surgery. Transoesophageal echocardiography (TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. Moreover, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.

Keywords: Cirrhotic cardiomyopathy; Liver cirrhosis; Liver transplantation; Perioperative anaesthesia management; Transoesophageal echocardiography.

Figure 1

List of the 11 views suggested by the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists guidelines on basic perioperative transoesophageal echocardiography. Modified from Reeves et al[28]. ME: Mid esophageal; LAX: Long axis view.

Figure 2

Transoesophageal echocardiography view (mid esophageal long axis view) used to measure left ventricular outflow tract diameter usually best imaged at a multiplane angle of 110°-140°. AV: Aortic valve; LA: Left atrium; LV: Left ventricle; RV: Right ventricle; ME AV LAX: Mid esophageal aortic valve long axis view. Modified by Møller-Sørensen et al[45].

Figure 3

Transoesophageal echocardiography view (deep transgastric long axis view), used to measure velocity time integral. AV: Aortic valve; LA: Left atrium; LV: Left ventricle; aA: Ascending aorta; TG LAX: Transgastric long axis view. Modified by Møller-Sørensen et al[45].

Figure 4

Transesophageal measurement of aortic valve planimetry from mid esophageal aortic valve SAX, usually best imaged at a multiplane angle of 40°-60°.

Figure 5

Transesophageal measurements of left ventricular length and minor left ventricular diameter from the ME 2C, usually best imaged at a multiplane angle of approximately 60°-90° and from the trans-gastric two-chamber view of the left ventricle, usually best imaged at an angle of approximately 90°-110°. L: Length; LVD: Left ventricular diameter.

Figure 6

Transesophageal measurements of fractional area change. Transgastric Mid SAX view of the left ventricle showing measurement of left ventricular end diastolic area (A) and left ventricular end-systolic area (B). The bidimensional image is usually best imaged at a multiplane angle of 0°. Modified by Guarracino Fabio et al[61].

Figure 7

Transesophageal measurements of fractional shortening. A: TG Mid SAX view of the left ventricle showing M-mode measurement of LVEDD and LVESD normalized for LVEDD. The bidimensional image is usually best imaged at a multiplane angle of 0°; B: TG LAX view of left ventricle showing M-Mode measurement of LVEDD and LVESD normalized for LVEDD usually best imaged at an angle of approximately 80°-110°. LAX: Long axis view; TG: Transgastric; LVEDD: Left ventricle end diastolic diameter; LVESD: Left ventricle end systolic diameter. Modified by Guarracino Fabio et al[61].

Figure 8

Calculation of ejection fraction using the disc method (Simpson's rule). Transoesophageal echocardiography ME 4C view in diastole (A) and systole (B). The bidimensional image is usually best imaged at a multiplane angle of 0°. Modified by Guarracino Fabio et al[61]. EDV: End diastolic volume; ESV: End-systolic volume.