Intracardiac thrombosis and its management during liver transplantation: international, multi-center, case-control study

Abstract

Background: Intracardiac thrombosis (ICT) during liver transplantation (LT) is a rare but life-threatening complication with limited data regarding its risk factors, management, and outcomes. This study aimed to identify factors associated with ICT development, define predictors of intraoperative outcomes and propose a novel classification and management algorithm for ICT.

Methods: A multicenter, international retrospective case-control study was conducted on liver transplant recipients from seven centers between January 2005 and December 2023. ICT cases were identified through transesophageal echocardiography (TEE) or autopsy and matched 1:1 with controls.

Results: Among 11 077 liver transplant recipients screened, 133 patients (1.2%) developed ICT. ICT occurred predominantly after reperfusion (58%). Compared to controls, ICT cases exhibited higher preoperative INR (p = 0.001) and fibrinogen levels (p = 0.014). Post-reperfusion syndrome (p < 0.001), disseminated intravascular coagulation (p < 0.001) and primary graft failure (p = 0.002) were also more common in the ICT group. Continuous veno-venous hemofiltration (CVVH) during surgery (OR 8.20, 95%CI: 2.09-38.1;p = 0.004) was associated with ICT development. ICT was associated with markedly higher rates of cardiac arrest (p < 0.001) and intraoperative mortality (p < 0.001), with thrombus location in the left heart chambers representing a significant predictor of mortality (OR 20.7, 95%CI:6.25-81.3;p < 0.001). ICT grade 2 and 3 were associated with a markedly increased risk of intraoperative cardiac arrest (p < 0.05). Importantly, delayed use of TEE was strongly associated with intraoperative death (OR 6.27, 95%CI 1.45,27.1;p = 0.014). The 90-day mortality was 43% in ICT cases compared to 4.5% in controls, while 1-year mortality was 46% vs. 10.5%, respectively.

Conclusions: ICT during LT is a rare but severe complication associated with intraoperative mortality and poor short-term survival. Coagulation profile and intraoperative management play critical roles in ICT development. The early use of TEE enables timely diagnosis and intervention, improving patient outcomes. We propose a novel ICT classification offering a systematic framework for risk stratification and management to mitigate progression and mortality.

Keywords: cardiac arrest; case-control study; coagulopathy; liver transplant; transesophageal echocardiography; unites states of america.