title: Haemostatic management for aortic valve replacement in a patient with advanced liver disease.
abstract: Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, platelet activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like "post-perfusion-syndrome" also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Laurence
authors.initials: L
authors.lastname: Weinberg
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Irene
authors.initials: I
authors.lastname: Kearsey
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Clarissa
authors.initials: C
authors.lastname: Tjoakarfa
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: George
authors.initials: G
authors.lastname: Matalanis
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Sean
authors.initials: S
authors.lastname: Galvin
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Scott
authors.initials: S
authors.lastname: Carson
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Bellomo
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Larry
authors.initials: L
authors.lastname: McNicol
authors.affiliation: Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: McCall
keywords: Cardiac surgery; Cardiopulmonary bypass; Coagulopathy; Liver failure