Management of Intracardiac Thrombus During Orthotopic Liver Transplant

Liver transplant is the only definitive treatment for end-stage liver disease, which can be caused by pharmacologic, oncologic, metabolic, and iatrogenic factors. End-stage liver disease leads to altered physiology of multiple organ systems, most notable cardiac, pulmonary, and hematologic/coagulation. As a result, the anesthesiologist faces many intraoperative challenges. This chapter describes the intraoperative resuscitation of a patient with end-stage liver disease secondary to malignancy and details the intricate management of complications from an unexpected large right atrial thrombus and associated prothrombotic and coagulopathic changes. We also describe in detail manifestations of end-stage liver disease and their anesthetic impact, the role of transesophageal echocardiography, specific anesthetic considerations during the different stages of liver transplant, management of massive hemorrhage including a rapid blood infuser, and diagnosis and treatment of coagulopathies.