Intraoperative management to prevent cardiac collapse in a patient with a recurrent, large-volume pericardial effusion and paroxysmal atrial fibrillation during liver transplantation: A case report

Abstract Background Pericardial effusion is a common feature of end-stage liver disease. This case report describes the intraoperative management of recurrent pericardial effusion, without re-pericardiocentesis, to prevent circulatory collapse during a critical surgical time point, i.e., manipulation of the major vessels and graft reperfusion. Case Report A 47-year-old female with hepatitis B was scheduled to undergo deceased-donor liver transplantation (LT). A large pericardial effusion was preoperatively identified using transthoracic echocardiography (TTE). The patient also had paroxysmal atrial fibrillation. Two days before surgery, preemptive pericardiocentesis was performed and the 1,150-mL effusion was drained. Intraoperatively, recurrence of the large pericardial effusion was identified using transesophageal echocardiography (TEE). During inferior vena cava manipulation, the surgeon consulted the anesthesiologist to evaluate the hemodynamic changes in the patient. After three attempts, the transplant team was able to determine the most appropriate anastomosis site, defined as that with the least impact on cardiac function. To prevent the development of severe postreperfusion syndrome, 10% MgSO 4 (2 g) was gradually infused 20 min before portal vein declamping, and immediately before graft reperfusion a 100-μg bolus of epinephrine was administered. During graft reperfusion, there was no evidence of heart chamber collapse or flow disturbance, as seen on the TEE findings. Postoperatively, the patient recovered completely and was discharged from the hospital. Six months after surgery, there was no sign of pericardial effusion on follow-up TTE. Conclusions Our intraoperative strategy may prevent cardiac collapse in patients with pericardial effusion detected during LT. Intraoperative TEE plays an important role in guiding hemodynamic management.