TPES 2024: Dr Cosmin Guta "TEE for liver transplant"

thanks so much for that Jen I think we're going to have a lot of questions regarding Echo for lung transplantation in the Q&A so we'll move on to our next lecture which is Dr cosmin Guta speaking on te for liver transplantation so Dr cosmin Guta completed his residency in 2003 at Columbia University in New York he subsequently pursued a fellowship in cardiac anesthesia at Stanford University where he served as an attending physician specializing in cardiac and liver transplant in 2013 Dr Guta joined Cleveland Clinic Florida where he established the liver transplant program and later assumed the role of program director for The Residency program after several years in private practice he returned to Academia at the University of Miami focusing on liver transplant and cardiac anesthesia thank you and I'll hand over to Dr Guta I am Dr gut I am a liver transplant and cardiac anesthesiologist at the University of Miami I will be talking about transis of EOC cardiography in liver trans I have no disclosures transil echocardiography has become a key inoperative tool which provides a continuous realtime comprehensive cardiac assessment structure and function helps with early detection of potential intraoperative complications and has a reduced risk of complications compared to invasive monitoring like P catheters liver transplantation involves significant hemodynamic changes caused by both the underlying liver disease and the surgical procedure common challenges include a high cardiac output State specific to the serotic patients who are presenting with a hyperdynamic circulation decreased peripheral vascular resistance secondary to portal hypertension and systemic baso dilation due to increased nitric oxide production and cytic cardiomyopathy which is characterized by both systolic and diastolic dysfunction which may be exacerbated by the stress of surgery most common findings during All Phases of liver transplantation are amboi which may vary from micro ulite to cluts ventricular dysfunction right left or B ventricular unrecognized preap pfos with a left to right flow a hyperdynamic ventricle and hypo volum a 2014 survey of high volume liver transplantation centers in US defined as at least 50 liver transplant cases a year found a 95% overall intraoperative te usage rate with 30% of the centers using te routinely while 57% were using it in special or rescue conditions only 26% of the responders had an advanced per up te certification with only 29% of them practicing cardiac anesthesia on a regular basis the survey did not find any uniform criteria regarding te certification requirements between the center surveyed a 2024 published survey that including us and non- US centers found an increase in routine use of te in us with only 21% of non- us centers using te routinely the common obstacles for routine use of te were lack of training and sometimes equipment most of the surveyed practitioners did The Limited te exam and the majority of them agreed that te certification is essential for becoming proficient to maximize the effectiveness of te during liver transplant a structured intraoperative protocol should be followed a set of predefined T views like moph for chamber medel long AIS and transgastric mid short AIS views should be routinely used at specific points during the surgery the standardized training in this protocol call is essential to ensure that all team members are proficient in using te and can respond effectively to the data it provides because the comprehensive te exam is technically complex and may require prolonged period to be performed more limited Protocols are being evaluated for patient assessment during liver transplant a specific 5 years protocol has been suggested to help clinicians Di noosed critical pathology and guide clinical management bario suggested a comprehensive Baseline exam during the dissection phase followed by a more focused assessment during neohepatic phase and The Limited T Pro manipulation during anhepatic phase with a focus on the med safel use although rare complications such asag injury and dental trauma can occur particularly in patients with predisposing conditions te should be used to caution in patients with esophagal parisis severe coagulopathy or recent upper GI surgery due to the increased risk of complications if the patient is considered to be at risk for complications it is recommended to limit the probe insertion to the Mida gel level avoid a wide range of probe Flex or manipulation of the probe in a fixed flexion position and limit the manipulation of the probe during the anhepatic phase that is because the IVC clamping during the anhepatic phase can cause an increase in the hepatic V expression and result in encouragement of the vares a 2024 study reported a 0.86 rate of major complications which is slightly higher than the 0.2% report in the cardiac literature there are very few absolute country indications for the use of te but the presence of esophagal disease probably is the greatest risk and would be an absolute contraindication the sagil vares grade one and grade two are considered a relative contraindication for Te for grade three vares the transgastric and deep trans gastric views should be avoided because viruses located near the G Junction tend to be most superficial and vulnerable liver transplant surgery can be divided into three main phases each presenting unique challenges the preanhepatic phase or the dissection phase is associated with a significant blood loss and fluid shifts due to the extensive dissection and the mobilization of the Li liver the anhepatic phase is characterized by a decreased Venus return and cardiac output secondary to partial or complete IVC clamping and portal pain clamping the neohepatic or reperfusion phase starts at the reperfusion of the new liver and can lead to the reperfusion syndrome marked by severe hemodynamic instability preanhepatic phase is defined as the period between anesthesia induction and portal clamping prior to incision a full T exam will evaluate cardiac structures and function and determine or help the correct placement of different vascular catheters from Central Venus catheter PA catheter or canul for VV bypass in case this is used during the procedure te is also used to Di the presence of plural or pericardial infusions and to guide their surgical drainage if indicated after the surgical incision the preanhepatic phase may include alterations in the preload secondary to drainage of a ctis bleeding or compression of the IVC several T views are critical for evaluating L ventricular function during liver trans transplant medag four chamber view provides a comprehensive view of the cardiac function Meda long axis view is used to assess L ventricular outflow tract diameter and detect Dynamic lot obstruction which can be a critical complication during liver transplant transgastric me short taxis view is important for assessing Li ventricular and diastolic area and volume status which are key indicators of preload ventricular function can be estimated by visual assessment of the ejection fraction in the transgastric mid short axis view or objectively by measuring Le ventricular ejection fraction in midaf 4 chamber View using the modified Simpson method fractional area change or fractional shortening right ventricular function is especially important in patients undergoing liver transplant especially those with palmary hypertension a m saal four chamber view is used for the assessment of the right ventricle size and function and detection of any signs of right ventricular failure or right ventricular volume overload tapsy is a simple and effective measure of R ventricular function and it is measured using the M sail 4 chamber View in M mode ultrasound imaging by placing the cursor on the lateral track aspit anulus and measuring the distance between the lowest and the highest point of the curve a value less than 16 mm is considered abnormal for patients presenting with severe PTO pulm hypertension te findings for severe paly hypertension can be evaluated in a midis Sagel four chamber View and include right ventricular dilation right ventricular hypokinesia decreased stsy and a d-shape interventricular SE an accurate assessment of preload is important for guiding throughing therapy during liver transplant measuring the area of left ventricle in transgastric mid short taxis view can help differentiate between hypovolemia and decreased pressure vascular resistance hypovolemia is a associated with a decreased left ventricular and systolic and and diastolic area while a decreas in peripheral vasular resistance is associated with a small an systolic area and a normal anic area the presence of the kissing papillary muscle sign in transgastric mid short taxis view indicat severe hypo volumia and the need for aggressive fluid resuscitation te allows for dynamic assessment of f responsiveness by evaluating changes in indolic area and L ventricular stroke volume during fluid administration te Acquired and diastolic volume measurements were more reliable than standard pressure monitoring to estimate L ventricular preload Dynamic lvot obstruction is a serious complication that can occur during liver transplant especially in patients with a small L ventricular size basil seal hypertrophy and systolic anterior motion of the mital valve lelet te is critical for early detection of the dynamic lvot obstruction by using the moph long axis view to visualize any signs of Sam or turbulent flow at the level of the lvot dynamic lvot obstru ction will be managed with fluid resuscitation increased after load and the reduction the mitro cardial contractility if the LV obstruction is secondary to an underfill left ventricle caused by a right ventricular failure Focus will be on the right ventricular support to promote forward flow to the left side of the heart an undiagnosed priia PFO can cause hypoxemia and paradoxical embolic phenomena when right atrial pressure exceeds left atrial pressure air or clots can embolize the coronary arteries particularly the right coronary artery producing hypokinesia and severe RV dilation or to the Ser circulation causing neurological compromise a medel bable view should be used the transducer angle rotated between 90 and 110° and the probe turned clockwise the the interatrial septum should be examined with and without color flow since atrial septal anisms may be associated with interatrial shuns the anhepatic phase starts with the occlusion of vascular blood flow to the liver and ends with a gra reperfusion the hemodynamic changes that occur in the space are mainly caused by partial or complete clamping of the IVC and portal vein clamping is used to detect decreased systemic vascular resistance and hypovolemia hemodynamic instability caused by changes in myocardial contractivity right or biventricular dysfunction and intracardiac cluts the M for chamber and transgastric mid short taxis views are ideal for distinguishing between these patterns because both allow continuous monitoring of the biventricular function and volume status during the antipathic stage te images were reported to provide better information in differentiating between two common causes of hypotension inadequate Venus return and lvot obstruction the neohepatic or reperfusion phase starts with the reperfusion of the new CFT after the completion of the portal an asmosis and unclamping of the portal vein and it is associated with consider hemodynamic instability reperfusion syndrome occurs when liver graft reperfusion causes significant cardiovascular changes and is it is defined as a decrease in the mean arterial pressure over the % below the Baseline value lasting for at least 1 minute occurring during the first 5 minutes after reperfusion of the liver graft and associated with Brady cardia and increased ponary vascular resistance Med for chamber transgastric mature taxes views are usually used to identify ventricular dysfunction right left or B ventricular intracardiac trombosis mitro trasit Val regurgitation and significant amounts of Venus air intracardiac trombosis has a reporting incidence that varies between 0.36% up to 6% but it is probably under reported in the the literature it can occur during the preanhepatic phase or the reperfusion phase has a clinical presentation which includes a sudden increase in the palmary artery pressure associated with systemic hypotension and possible Cardiac Arrest it can be detected most commonly during post reperfusion by using a mop 4 chamber view routine te will lead to better detection and selective use which could allow under diagnosis and potentially delays time sensitive treatment acute right heart failure may be a component of preperfusion syndrome or an exacerbation of preexisting dysfunction it presents as right ventricular dilation new onset Tri cosit regurgitation or leftward shift of the interatrial or interventricular septi te can identify right ventricular dysfunction allowing for immediate corrective action in Tropic agents or inhale Pine vasodilators diastolic dysfunction is a common problem in patients with serotic cardiomyopathy it is characterized by impaired ventricular relaxation increased stiffness of The ventricle which can lead to elevated feeling pressures the mop 4 chamber fuel is used to evaluate trans mitroflow velocities and and tissue doler Imaging of the mital anulus which are key indicators of diastolic dysfunction diastolic dysfunction has been associated with an increased peroperative morbidity IM mortality making its assessment and management crucial during liver transplant de can be used to detect stenosis trombosis or kinking of the CFT at the Cy of vascular anastomosis particularly the IVC this can be visualized in M suffel by cable view by advancing and rotating the probe to the right to show the anastomosis site color dou te can be used to determine the flow through the IDC and the presence of a traas a perspective trial that us see Imaging of graft hepatic Venus flow showed that a decreased flow correlated with increased risk of death acute rejection prolonged operative time and the lay craft function a good understanding of KT views is essential for optimizing patients outcomes during liver transplant midaf for chamber view provides a global assessment of the cardiac function mapag and long access view is important for assessing the lvot and detecting Dynamic alot obstruction transing midore taxes View shows ventricular volume status and Regional wall motion abnormalities M Sail by cable view is essential for detecting air embolism and assessing the IVC and R atrial pressures meaa hepatic vein view is just for evaluating Venus return and detecting complications of the vascular anastomosis sites te is a continuous realtime monitor of hemodynamic changes allowing for immediate intervention when needed it can improve L transplant outcomes in rare but life-threatening conditions by helping with the diagnosis of intraoperative complications difficult to identify with monitors it is associated with better peroperative outcomes including reduced mortality and improved craft function the successful application of te in liver transplant depends on The Operators expertise and the use of well structured protocols thank you