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González-Suárez S, Serrano HA, Chocron IZ, Tormos P, Cano E, Galán P, de Nadal M, Matarín S, Cabeza M, Rodríguez-Tesouro AB. Postreperfusion Syndrome in Patients Receiving Vasoactive Drugs During Liver Graft Reperfusion. EXP CLIN TRANSPLANT 2024; 22:43-51. [PMID: 38284374 DOI: 10.6002/ect.2023.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The most widely used definition of postreperfusion syndrome in liver transplant is a 30% decrease in mean arterial pressure during the first 5 minutes after vascular unclamping. With these criteria, increased postoperative morbidity has been reported. Vasoactivedrugs couldpreventthis syndrome.Themain objective of our study was to determine the incidence and complications associated with postreperfusion syndrome inpatientswho receivedvasoactive support. MATERIALS AND METHODS We studied 246 patients who received norepinephrine infusions to maintain mean arterial pressure ≥60 mm Hg and who were monitored with a Swan-Ganz catheter. Patients received a bolus of adrenaline after vascular unclamping in cases of insufficient response to norepinephrine. RESULTS Among the study patients, 57 (23.17%) developed postreperfusion syndrome. Patients who developed postreperfusion syndrome did not present with morepostoperative complications interms ofrenal dysfunction (P = .69), repeat surgery (P = .15), graft rejection (P = .69), transplant replacement surgery (P = .76), hospital stay (P = .70), or survival (P = .17) compared with patients without postreperfusion syndrome. CONCLUSIONS In patients who underwent orthotopic liver transplant, in whom vasoactive drugs were administered, a diagnosis of self-limited postreperfusion syndrome during the first 5 minutes after unclamping may not be associated with postoperative complications. The administration of vasoconstrictors may have a preventive effect on the postoperative complications associated with postreperfusion syndrome or they may mask the real incidence of postreperfusion syndrome. A broader definition of postreperfusion syndrome should be accepted.
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Affiliation(s)
- Susana González-Suárez
- From the Department of Surgery, Universitat Autònoma de Barcelona, Unitat Docent Vall d'Hebron, Barcelona, Spain; and the Department of Anesthesiology and Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
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Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, Contreras-Yametti FI, Murthy S, Jorde UP. Cardiac risk stratification of the liver transplant candidate: A comprehensive review. World J Transplant 2022; 12:142-156. [PMID: 36051452 PMCID: PMC9331410 DOI: 10.5500/wjt.v12.i7.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
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Affiliation(s)
- Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
| | - Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
| | | | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
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Rudolph M, Schmeer CW, Günther M, Woitke F, Kathner-Schaffert C, Karapetow L, Lindner J, Lehmann T, Jirikowski G, Witte OW, Redecker C, Keiner S. Microglia-mediated phagocytosis of apoptotic nuclei is impaired in the adult murine hippocampus after stroke. Glia 2021; 69:2006-2022. [PMID: 33942391 DOI: 10.1002/glia.24009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 01/02/2023]
Abstract
Following stroke, neuronal death takes place both in the infarct region and in brain areas distal to the lesion site including the hippocampus. The hippocampus is critically involved in learning and memory processes and continuously generates new neurons. Dysregulation of adult neurogenesis may be associated with cognitive decline after a stroke lesion. In particular, proliferation of precursor cells and the formation of new neurons are increased after lesion. Within the first week, many new precursor cells die during development. How dying precursors are removed from the hippocampus and to what extent phagocytosis takes place after stroke is still not clear. Here, we evaluated the effect of a prefrontal stroke lesion on the phagocytic activity of microglia in the dentate gyrus (DG) of the hippocampus. Three-months-old C57BL/6J mice were injected once with the proliferation marker BrdU (250 mg/kg) 6 hr after a middle cerebral artery occlusion or sham surgery. The number of apoptotic cells and the phagocytic capacity of the microglia were evaluated by means of immunohistochemistry, confocal microscopy, and 3D-reconstructions. We found a transient but significant increase in the number of apoptotic cells in the DG early after stroke, associated with impaired removal by microglia. Interestingly, phagocytosis of newly generated precursor cells was not affected. Our study shows that a prefrontal stroke lesion affects phagocytosis of apoptotic cells in the DG, a region distal to the lesion core. Whether disturbed phagocytosis might contribute to inflammatory- and maladaptive processes including cognitive impairment following stroke needs to be further investigated.
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Affiliation(s)
- Max Rudolph
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Christian W Schmeer
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Madlen Günther
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Florus Woitke
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Lina Karapetow
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Julia Lindner
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics and Computer Science, University Hospital Jena, Friedrich Schiller University Jena, Jena, Germany
| | - Gustav Jirikowski
- Health and Medical University Potsdam, University Potsdam, Potsdam, Germany
| | - Otto W Witte
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Christoph Redecker
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany.,Department of Neurology, Lippe General Hospital, Lemgo, Germany
| | - Silke Keiner
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
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Cirrhotic Cardiomyopathy - A Veiled Threat. Cardiol Rev 2020; 30:80-89. [PMID: 33229904 DOI: 10.1097/crd.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.
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Taura P, Martinez-Palli G, Blasi A, Rivas E, Beltran J, Balust J. Intraoperative Management of High-Risk Liver Transplant Recipients: Concerns and Challenges. Transplant Proc 2017; 48:2491-2494. [PMID: 27742332 DOI: 10.1016/j.transproceed.2016.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Liver transplantation (LT) offers patients with liver disease a real chance for long-term survival. In the past decade, successful survival after LT along with the Model for End-Stage Liver Disease-based allocation policy have increased willingness to accept patients with a higher risk profile and marginal organs and to prioritize the sickest patients on the waiting list. Therefore, the anesthesiologist now deals with very challenging patients. In the present review, we aimed to highlight key aspects of intraoperative LT management in high-risk patients and to place these aspects in the perspective of their impact on perioperative outcomes. Conservative standardized perioperative strategies mandate a switch toward accurate and tailored perioperative anesthetic care to maintain the steady improvement in recipient survival rates after LT. In our opinion, continuous assessment of fluid status and cardiac performance, strategies promoting graft decongestion, rational hemostatic management, and the identification of LT recipients with potential risk of vascular complications should constitute the cornerstone of intraoperative management.
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Affiliation(s)
- P Taura
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
| | - G Martinez-Palli
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - A Blasi
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - E Rivas
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - J Beltran
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - J Balust
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Blasi A, Hernandez V, Fernandez J, Colmenero J, Beltran J, Garcia-Valdecasas JC, Reverter JC. Venous Thrombotic Events After Liver Transplantation. Clin Appl Thromb Hemost 2016; 24:317-322. [PMID: 27899521 DOI: 10.1177/1076029616680477] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Thromboprophylaxis is not well defined after liver transplantation (LT). The aim of this study was to evaluate the incidence of splanchnic vein thrombosis (SVT) and nonsplanchnic vein thrombosis (NSVT) after LT. Liver transplantations performed between 2009 and 2013 in our institution were reviewed. Demographic, intraoperative, and postoperative data were recorded. Low-molecular-weight heparin was only administered postoperatively if intraoperative thrombectomy was performed or in patients preoperatively anticoagulated. Of a total of 328 patients, 72% were male with a median age of 56 years, score of model for end-stage liver disease 18 (11-23), and 88% had liver cirrhosis. The incidence of postoperative venous thrombotic events was 4.6%: 8 (2.4%) patients had SVT and 7 (2.1%) patients had NSVT. After logistic regression analysis, intraoperative thrombectomy and Child A classification emerged as risk factors for SVT (odds ratio [OR]: 77, 95% confidence interval [95% CI]: 14-421) and NSVT (OR: 20, 95% CI: 3-170), respectively. The incidence of SVT in patients who undergo intraoperative thrombectomy was 33%, whereas the incidence of NSVT in patients grouped as Child A was 7.5%. Our results suggest that thromboprophylaxis should be considered after LT in patients with cirrhosis grouped as Child A and in patients who undergo intraoperative thrombectomy.
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Affiliation(s)
- Annabel Blasi
- 1 Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Virginia Hernandez
- 2 Hepatic Hemodynamic Laboratory, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Javier Fernandez
- 3 Hepatology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Jordi Colmenero
- 3 Hepatology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Joan Beltran
- 1 Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Joan Carles Reverter
- 5 Hemotherapy Hemostasis Department, Hospital Clinic de Barcelona, Barcelona, Spain
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Siniscalchi A, Gamberini L, Laici C, Bardi T, Ercolani G, Lorenzini L, Faenza S. Post reperfusion syndrome during liver transplantation: From pathophysiology to therapy and preventive strategies. World J Gastroenterol 2016; 22:1551-1569. [PMID: 26819522 PMCID: PMC4721988 DOI: 10.3748/wjg.v22.i4.1551] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 10/20/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
This review aims at evaluating the existing evidence regarding post reperfusion syndrome, providing a description of the pathophysiologic mechanisms involved and possible management and preventive strategies. A PubMed search was conducted using the MeSH database, “Reperfusion” AND “liver transplantation” were the combined MeSH headings; EMBASE and the Cochrane library were also searched using the same terms. 52 relevant studies and one ongoing trial were found. The concept of post reperfusion syndrome has evolved through years to a multisystemic disorder. The implications of the main organ, recipient and procedure related factors in the genesis of this complex syndrome are discussed in the text as the novel pharmacologic and technical approaches to reduce its incidence. However the available evidence about risk factors, physiopathology and preventive measures is still confusing, the presence of two main definitions and the numerosity of possible confounding factors greatly complicates the interpretation of the studies.
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Ruiz-del-Árbol L, Serradilla R. Cirrhotic cardiomyopathy. World J Gastroenterol 2015; 21:11502-11521. [PMID: 26556983 PMCID: PMC4631957 DOI: 10.3748/wjg.v21.i41.11502] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/17/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
During the course of cirrhosis, there is a progressive deterioration of cardiac function manifested by the disappearance of the hyperdynamic circulation due to a failure in heart function with decreased cardiac output. This is due to a deterioration in inotropic and chronotropic function which takes place in parallel with a diastolic dysfunction and cardiac hypertrophy in the absence of other known cardiac disease. Other findings of this specific cardiomyopathy include impaired contractile responsiveness to stress stimuli and electrophysiological abnormalities with prolonged QT interval. The pathogenic mechanisms of cirrhotic cardiomyopathy include impairment of the b-adrenergic receptor signalling, abnormal cardiomyocyte membrane lipid composition and biophysical properties, ion channel defects and overactivity of humoral cardiodepressant factors. Cirrhotic cardiomyopathy may be difficult to determine due to the lack of a specific diagnosis test. However, an echocardiogram allows the detection of the diastolic dysfunction and the E/e′ ratio may be used in the follow-up progression of the illness. Cirrhotic cardiomyopathy plays an important role in the pathogenesis of the impairment of effective arterial blood volume and correlates with the degree of liver failure. A clinical consequence of cardiac dysfunction is an inadequate cardiac response in the setting of vascular stress that may result in renal hypoperfusion leading to renal failure. The prognosis is difficult to establish but the severity of diastolic dysfunction may be a marker of mortality risk. Treatment is non-specific and liver transplantation may normalize the cardiac function.
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