title: Pulmonary thromboembolism during adult liver transplantation: incidence, clinical presentation, outcome, risk factors, and diagnostic predictors.
abstract: BACKGROUND
  Intraoperative pulmonary thromboembolism (PTE) is an often overlooked cause of mortality during adult liver transplantation (LT) with diagnostic challenge. The goals of this study were to investigate the incidence, clinical presentation, and outcome of PTE and to identify risk factors or diagnostic predictors for PTE.
  
  
  METHODS
  Four hundred and ninety-five consecutive, isolated, deceased donor LTs performed in an institution for a 3 yr period (2004-6) were analysed. The standard technique was a piggyback method with veno-venous bypass without prophylactic anti-fibrinolytics. The clinical diagnosis of PTE was made with (i) acute cor pulmonale, and (ii) identification of blood clots in the pulmonary artery or observation of acute right heart pressure overload with or without intracardiac clots with transoesophageal echocardiography.
  
  
  RESULTS
  The incidence of PTE was 4.0% (20 cases); cardiac arrest preceded the diagnosis of PTE [75% (15)] and PTE occurred during the neo-hepatic phase [85% (17)], especially within 30 min after graft reperfusion [70% (14)]. Operative and 60 day mortalities of patients with PTE were higher (P<0.001) than those without PTE (30% vs 0.8% and 45% vs 6.5%). Comparison of perioperative data between the PTE group (n=20) and the non-PTE group (n=475) revealed cardiac arrest and flat-line thromboelastography in three channels (natural, amicar, and protamine) at 5 min after graft reperfusion as the most significant risk factors or diagnostic predictors for PTE with an odds ratio of 154.32 [95% confidence interval (CI): 44.82-531.4] and 49.44 (CI: 15.6-156.57), respectively.
  
  
  CONCLUSIONS
  These findings confirmed clinical significance of PTE during adult LT and suggested the possibility of predicting this devastating complication.
authors.affiliation: Department of Anesthesiology, University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA. sakait@upmc.edu
authors.forename: T
authors.initials: T
authors.lastname: Sakai
authors.forename: T
authors.initials: T
authors.lastname: Matsusaki
authors.forename: F
authors.initials: F
authors.lastname: Dai
authors.forename: K A
authors.initials: KA
authors.lastname: Tanaka
authors.forename: J B
authors.initials: JB
authors.lastname: Donaldson
authors.forename: I A
authors.initials: IA
authors.lastname: Hilmi
authors.forename: J
authors.initials: J
authors.lastname: Wallis Marsh
authors.forename: R M
authors.initials: RM
authors.lastname: Planinsic
authors.forename: A
authors.initials: A
authors.lastname: Humar
mesh_terms: D000328:Adult; D000368:Aged; D004812:Epidemiologic Methods; D005260:Female; D006085:Graft Survival; D006801:Humans; D007431:Intraoperative Complications; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D057234:Preoperative Period; D011379:Prognosis; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D013916:Thrombelastography; D016896:Treatment Outcome; D055815:Young Adult