Utility of transesophageal echocardiography during orthotopic liver transplantation: A narrative review

Abstract

Orthotopic liver transplantation (OLT) is the standard of care for patients suffering from end stage liver disease (ESLD). This is a high-risk procedure with the potential for hemorrhage, large shifts in preload and afterload, and release of vasoactive mediators that can have profound effects on hemodynamic equilibrium. In addition, patients with ESLD can have preexisting coronary artery disease, cirrhotic cardiomyopathy, porto-pulomary hypertension and imbalanced coagulation. As cardiovascular involvement is invariable and patient are at an appreciable risk of intraoperative cardiac arrest, Trans esophageal echocardiography (TEE) is increasingly becoming a routinely utilized monitor during OLT in patients without contraindications to its use. A comprehensive TEE assessment performed by trained operators provides a wealth of information on baseline cardiac function, while a focused study specific for the ESLD patients can help in prompt diagnosis and treatment of critical events. Future studies utilizing TEE will eventually optimize examination safety, quality, permit patient risk stratification, provide intraoperative guidance, and allow for evaluation of graft vasculature.

Keywords: Hemodynamic assessment; liver transplantation; transesophageal echocardiography.

Figure 1

Midesophageal (ME) 4-chamber view: 2D image captured during anhepatic phase demonstrating systolic anterior motion of anterior mitral leaflet (SAM) causing with dynamic left ventricle outflow tract obstruction (LVOTO) mitral leaflet coaptation defect

Figure 2

ME 4-chamber view: color Doppler image captured during anhepatic phase demonstrating flow acceleration across LVOT and posteriorly directed moderate mitral regurgitation jet

Figure 3

ME right ventricle inflow-outflow tract view during reperfusion demonstrating intracardiac thrombus in the IVC extending into the right atrium

Figure 4

Transthoracic apical 4-chamber view demonstrating a peri-membranous ventricular septal defect with a left to right shunt

Figure 5

ME aortic valve long-axis view with intraoperative color Doppler showing diastolic regurgitant flow acceleration across the aortic valve in a recipient undergoing living related liver transplant

Figure 6

ME descending thoracic aorta long-axis view of the same patient from Figure 5. Spectral Doppler waveform reveals holo-diastolic flow reversal, suggesting significant aortic incompetence