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BACKGROUND

  • Cardiopulmonary complications after orthotopic liver transplantation are common, at rates reported between 25% and 70%, which is higher than for other solid organ transplants.1–3

  • Represents the third leading cause of death behind infection and rejection (22% of all late mortalities).4

  • Although the principal risk factors for development of these events are the intraoperative transfusion and the patient age, other causes of this higher rate among liver transplant patients remains unknown.

  • Most occur within the first 6 months (early) after transplant.

  • Attempts to avoid these events are mandatory, mainly because they represent a major source of morbidity and mortality after liver transplantation.

THE TRANSPLANT EVALUATION TEAM

  • Cardiovascular events posttransplantation should be evaluated by a skilled multidisciplinary team, including the cardiology and pulmonology team.

  • Risks, benefits, and the process from preoperative evaluation to postoperative evaluation and long-term follow-up should be reviewed with the patient (when appropriate) and the family/caregivers in each step in order to determine whether to proceed or not based on an informed decision.

PREDICTIVE RISK FACTORS ASSOCIATED WITH CARDIOVASCULAR COMPLICATIONS

  • Pretransplant factors:5,6

    • Recipient’s age7

    • Hypercholesterolemia

    • Systolic hypertension

    • Severe ascites

    • Metabolic disturbances before liver transplant

    • Hyponatremia

    • Hyperhomocysteinemia

    • Severity of liver dysfunction (high integrated Model for End-Stage Liver Disease [MELD] score, high MELD-Na score, high MELD score)

    • Diastolic dysfunction (low E/A ratio and prolonged EDT)8

    • Elevated serum troponin levels

    • Elevated blood urea nitrogen (BUN)

    • Elevated brain natriuretic peptide (BNP)

    • Abnormal spirometry findings

    • Chronic alcohol consumption

    • Smoking history

    • Acute renal failure

    • Mechanical ventilation due to severe respiratory failure

    • High values of international normalized ratio (INR)

    • Deceased donor source of organ transplantation

    • Cirrhotic encephalopathy

    • Cardiac disease history:

      • Coronary artery disease (CAD)

      • Coronary artery bypass graft (CABG)

      • Valvulopathy

      • Percutaneous transluminal coronary angioplasty with stent placement (PTCA-STENT)

  • Major intraoperative risk factors:

    • Surgical procedure9,10

    • Intraoperative fluid transfusion volume9,11,12

    • Intraoperative blood transfusion volume11,13

    • Perioperative fluid balance11

    • Intraoperative fluid retention14

    • Intraoperative bleeding volumes14

  • Posttransplant factors:

    • Surgical ischemic times

    • Graft quality

    • Amount of intraoperative transfused blood and plasma

    • Decreased high-density lipoprotein cholesterol (HDL-C)

    • Renal impairment

    • Concomitant cardiopulmonary toxic drugs

    • Excessive perioperative fluid administration9

    • Delayed weaning from mechanical ventilation9,10,15

    • Acute rejection during the hospital stay9

    • Postoperative acute renal failure16

    • Postoperative hypoproteinemia

    • Onset of renal insufficiency

    • Poor postoperative myocardial function

    • Right hemidiaphragm paralysis17

    • Greater exposure to nosocomial agents18

    • Significant decline in the recipient’s immune function18

    • Surgical complications18

    • Reinterventions or need for retransplantation18

MANAGEMENT

  • Prevention:5

    • Preoperative strategies:

      • Pulmonary rehabilitation prior to orthoptic liver transplant (OLT)

    • Intraoperative strategies:

      • Reduction in the degree of surgical insult

      • Reduction in the level of aggressiveness

      • Reduction in the duration of the procedure

      • Reduction in the amount of blood lost

    • Postoperative strategies:

      • Early extubation

      • Adequate postoperative pain relief

      • Optimal hemodynamic and fluid management

      • Improvement of general health and nutrition

      • Lung expansion maneuvers

      • Deep breathing exercises

      • Timely execution of ...

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