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Table of Contents
LETTER TO EDITOR  
Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 227-229
Perioperative management of emergency aortic valve replacement for infective endocarditis after liver transplantation


1 Department of Cardiac Anesthesia, P.D. Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India
2 Department of Cardiac Surgery, P.D. Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India

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Date of Web Publication29-Jun-2013
 

How to cite this article:
Borde DP, Gandhe U, Hargave N, Pandey K. Perioperative management of emergency aortic valve replacement for infective endocarditis after liver transplantation. Ann Card Anaesth 2013;16:227-9

How to cite this URL:
Borde DP, Gandhe U, Hargave N, Pandey K. Perioperative management of emergency aortic valve replacement for infective endocarditis after liver transplantation. Ann Card Anaesth [serial online] 2013 [cited 2019 Dec 7];16:227-9. Available from: http://www.annals.in/text.asp?2013/16/3/227/114248


The Editor,

With the increased life expectancy and increased risks of cardiovascular diseases for liver allograft recipients, it would be reasonable to assume that the number of liver recipients in need of cardiac surgery could be increasing. A 36-year-old female with a history of cadaveric liver transplant for primary sclerosing cholangitis 6 months ago presented with fever, chills, and pain in the abdomen. On auscultation, grade IV/VI diastolic murmur was heard in aortic area. Transthoracic 2-D echocardiogram revealed vegetation on aortic valve (AV) measuring 14 mm × 7 mm; and severe aortic regurgitation (AR) was noted with a vena contracta width of 8 mm. There was a suspicious lesion on anterior leaflet of mitral valve (MV) with moderate mitral regurgitation (MR). The blood culture was positive for streptococcus viridians. According to the modified Duke's criteria, diagnosis of infective endocarditis was considered. Antibiotic treatment with intravenous ceftriaxone was started and patient was referred for emergency AV replacement with a possible MV replacement. The laboratory investigations showed Hb 7.8 g/dL, normal liver function tests, and serum creatinine 1 mg/dL. Ultrasonography of abdomen revealed normal echo-texture of liver parenchyma. Pre-operative immunosuppression regimen comprised tacrolimus 1.5 mg twice daily. The pre-operative Model for End-Stage Liver Disease (MELD) score was eight.

Anesthesia was induced with titrated doses of midazolam (0.02 mg/kg), fentanyl (2 μg/kg), and etomidate (0.2 mg/kg). Rocuronium (0.9 mg/kg) was administered to facilitate endotracheal intubation. Anesthesia was maintained with sevoflurane in O 2 and air with infusions of midazolam (20-50 μg/kg/h), fentanyl (1-2 μg/kg/h) and atracurium (0.5 mg/kg/h). Antibiotic prophylaxis included ceftriaxone and teicoplanin. Methyl prednisone 500 mg bolus was administered after induction. Perioperative tacrolimus was continued through nasogastric tube. Transesophageal echocardiogram (TEE) before cardiopulmonary bypass (CPB) confirmed severe AR. In the mid-esophageal views, tip of the anterior leaflet of MV was thickened without evidence of vegetation [Figure 1]. Color-flow Doppler in midesophageal views showed moderate MR (vena contracta width 3 mm). It was decided to leave MV as such (MR was attributed to dilated left ventricle (LV) with structurally normal MV) and replace AV with a mechanical prosthesis. During CPB, a minimum flow of 2.2 L/min/m 2 and a perfusion pressure of > 60 mmHg were maintained. CPB and aortic Cross Clamp times were 78 min and 55 min, respectively. Hemodilution was avoided, two units packed red cells were added to CPB prime and another two units were transfused after weaning from CPB; lowest hematocrit was 20.5%. Weaning from CPB was facilitated with dopamine 10 μg/kg/min. Post-CPB, TEE demonstrated non-obstructed AV prosthesis without intra or para-valvular leak and only a mild MR. At the end of surgical procedure, patient was electively ventilated and weaned off the ventilator within 12 h. Chest tube drain was 200 mL in 24 h. Liver transplant surgeon closely monitored allograft function with meticulous maintenance of immunosuppression. With the increase in creatinine to 1.5 mg/dL, the dose of tacrolimus was reduced to 1 mg daily and mycophenolate mofetil (MMF) 1.5 g twice a day and low dose steroids (20 mg prednisone) were started. After 4 days when creatinine returned to normal, MMF was stopped and steroids rapidly tapered. Patient was discharged on the post-operative day (POD) 7 after uneventful course. On current follow-up patient is doing well with normal creatinine and monotherapy with tacrolimus.
Figure 1: Note perforation in aortic cusps with severe aortic regurgitation. Mitral valve is structurally normal. Left ventricle is dilated

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Our experience of this case suggest that cardiac surgery can be safely performed in patients with liver transplant; however, in such patients undergoing cardiac surgery, the perioperative surgical risk should be stratified, the intra-operative choice of anesthetic drugs are important and may increase the risk of complications, and the adjustment of immunosuppressive regimens is important to prevent the allograft dysfunction. It has been reported that the survival rate of liver transplant recipients is 84% at 1 year and 67% at 5 years. The MELD score (range: 6-40) is a good predictor of mortality in patients on the waiting list for liver transplant and post-liver transplant mortality and has recently been used to predict perioperative mortality in the different categories of surgery. In a recent series of patients for various cardiac surgeries with transplanted liver, the optimal cut off value of MELD was identified as 13.5. [1] Studies have shown that volatile anesthetics and drugs that are metabolized by the liver can be safely administered to patients after liver transplant. It is important to appreciate that after successful liver transplantation, the previously diminished pro-coagulant factors achieve normal activity by POD one to two, fibrinolytic activity by POD four to seven and anticoagulant factors by POD 7-14. By the 2 nd week post-transplantation, hepatic synthetic activity is effectively normal. [2] Transient allograft dysfunction is a common finding in patients with liver transplantation undergoing cardiac surgery. Liver function testing remains a very important tool in assessing the functional status of the transplanted liver. Persistent elevation of bilirubin and alkaline phosphatase may suggest bile duct obstruction. Elevated aspartate aminotransferase is the most sensitive test to detect rejection. [2]

Intra-operative TEE is useful to determine the location and extent of infection, guide surgery, assess the result. It is important to realize that elderly patients with impaired LV function undergoing complex cardiac procedures [3],[4],[5],[6] are at increased risk of post-operative complications, the most common being respiratory insufficiency, renal failure, biliary leakage, and bleeding with increased need of transfusion.

To summarize, improvement in outcome of liver recipients undergoing cardiac surgery is multifactorial and related to improvement of immunosuppressive treatment, antibiotic prophylaxis, and advances in perioperative management and surgical techniques. Present case illustrates the importance of an interdisciplinary approach for managing such high risk patients.


   Acknowledgment Top


The authors would like to thank Dr. Shreedhar Joshi for his help in preparation of this manuscript.

 
   References Top

1.Ota T, Rocha R, Wei LM, Toyoda Y, Gleason TG, Bermudez C. Surgical outcomes after cardiac surgery in liver transplant recipients. J Thorac Cardiovasc Surg 2013;145:1072-6.  Back to cited text no. 1
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2.Tran SB. Anesthetic considerations for patients post-0rgan transplantation. Semin Anesth Perioper Med Pain 2003;22:119-24.  Back to cited text no. 2
    
3.Filsoufi F, Rahmanian PB, Castillo JG, Karlof E, Schiano TD, Adams DH. Excellent results of cardiac surgery in patients with previous liver transplantation. Liver Transpl 2007;13:1317-23.  Back to cited text no. 3
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4.Deb SJ, Mullany CJ, Kamath PS, Dearani JA, Daly RC, Orszulak TA, et al. Cardiac surgery in kidney and liver transplant recipients. Mayo Clin Proc 2006;81:917-22.  Back to cited text no. 4
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5.Prabhakar G, Testa G, Abbasoglu O, Jeyarajah DR, Goldstein RM, Levy MF, et al. The safety of cardiac operations in the liver transplant recipient. Ann Thorac Surg 1998;65:1060-4.  Back to cited text no. 5
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6.Ono M, Wolf RK, Angouras DC, Brown DA, Goldstein AH, Michler RE. Short- and long-term results of open heart surgery in patients with abdominal solid organ transplant. Eur J Cardiothorac Surg 2002;21:1061-72.  Back to cited text no. 6
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Correspondence Address:
Deepak Prakash Borde
Department of Cardiac Anesthesia, P.D. Hinduja National Hospital, Mahim, Mumbai - 400 022, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.114248

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