Graft reperfusion of transplanted liver–perfect storm for coronary vasospasm

Major adverse cardiac events in patients during liver transplantation are due to preexisting cardiopulmonary comorbidities and the impact of surgery on hemodynamics. Graft reperfusion of the transplanted liver is the most hemodynamically critical phase and can be associated with air embolism and the release of acidotic, cold, hyperkalemic effluent containing vaso-constrictive chemical mediators such endothelin-1 and thromboxane A2. Concomitant release of oxygen reactive species can further sensitize the coronary vasculature to vasoconstrictors creating the perfect milieu for coronary vasospasm. We report a case in which myocardial ischemia accompanied by significant ST depression followed reperfusion possibly caused by coronary vasospasm. Correspondence to: Latha Hebbar, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, South Carolina, USA, E-mail: [email protected] Received: November 08, 2016; Accepted: December 24, 2016; Published: December 28, 2016 Introduction End-stage liver disease affects every organ system in the body leading to a very exhaustive preoperative workup to determine eligibility for a potential liver transplant. The AHA/ACA have established guidelines for cardiac workup of these patients, however, the frequency of surveillance while on the transplant waiting list is yet to be determined [1]. The anesthetic management of these cases is challenging with reperfusion of the transplanted graft being the most critical period. Hemodynamic changes observed during graft reperfusion include decreases in systemic vascular resistance (SVR) and mean arterial blood pressure (MAP), dysrhythmias, abrupt increases in mean PA pressure, CVP and PCWP, myocardial ischemia and cardiac arrest [2,3]. The causes of this spectrum of hemodynamic instability are multifactorial and complex. They include the sudden release of cold, acidotic, hyperkalemic preservation fluid along with vasoactive mediators into the systemic circulation, surgical anastomotic mishaps with accompanying blood loss and air embolism causing right ventricular outflow tract obstruction and failure [2-5]. Myocardial ischemia with accompanying ST-T wave changes can occur during graft reperfusion. An imbalance of myocardial oxygen supply vs demand due to systemic hypotension, profound anemia or paradoxical coronary air embolism could be contributory. We report a case of myocardial ischemia during liver reperfusion attributed to coronary vasospasm. The setting of graft reperfusion with associated decreases in core temperature, increases in endothelin-1 and thromboxane A2 levels and increases in reactive oxygen species (ROS) creates a perfect storm for this clinical phenomenon. This report describes the care of one patient who has provided us with written consent to disclose the management of his case.