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The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report

Received: 15 July 2021     Accepted: 18 August 2021     Published: 27 August 2021
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Abstract

The case report discusses a significant discrepancy between the pre-transplant cardiac evaluation and post-induction transesophageal echocardiography, leading to aborting the surgical procedure. The transthoracic echocardiography [TTE] pre-liver transplant indicated only a minor intracardiac shunt, while the post-induction transesophageal echocardiography [TEE] showed a large atrial septal defect with a more significant left to right shunt. The attempt to close the defect with a transcatheter closure device failed and the perioperative care team decided not to proceed with the liver transplantation. Later cardiac evaluation with cardiac magnetic resonance imaging demonstrated a secundum atrial septum defect in the inferior border of the interatrial septum with 43 ml flow difference between systemic and pulmonary circulation. The failure to identify a large atrial septal defect/inferior venosus defect in the preoperative screening process for liver transplantation resulted in failing to optimize the patient pre transplant. Although complications related to large atrial septal defects are rare during liver transplant (paradoxical embolisms, malignant arrhythmias, myocardial infarctions or cerebrovascular complications), they can be potentially fatal. The preoperative cardiac assessment should have included optimization of this congenital defect. The case report discusses implications of atrial septal defects for liver transplant and why the screening process may have missed the defect. The findings of a positive bubble study during the transthoracic echocardiography should not be trivialized and may require further workup.

Published in Journal of Surgery (Volume 9, Issue 4)
DOI 10.11648/j.js.20210904.21
Page(s) 204-208
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2021. Published by Science Publishing Group

Keywords

Liver Transplant, Atrial Septal Defect, Transthoracic Echocardiography, Transesophageal Echocardiography, Pre-liver Transplant Screening, Preoperative Optimization

References
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[2] Akagi T. Current concept of transcatheter closure of atrial septal defect in adults. J Cardiol. 2015; 65 (1): 17-25.
[3] Alba AC, Verocai Flaman F, Granton J, Delgado DH. Patent formaen ovale does not have a negative impact on early outcomes in patients undergoing liver transplantation. Clin Transplant. 2011; 25 (1): 151-5.
[4] Amedro P, Bayburt S, Assaidi A, et al. Should transcatheter closure of atrial septal defect with inferior-posterior deficient rim be attempted? J Thorc Dis. 2019; 11 (3): 708-16.
[5] Ayres NA, Miller-Hance W, Fyfe DA, et al. Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease: report from the task force of the Pediatric Council of the American Society of Echocardiography. J Am Soc Echocardiogr. 2005; 18 (1): 91-8.
[6] Concejero A, Chen CL, Liang CD, et al. Living donor liver transplantation in children with congenital heart disease. Tranplantation. 2007; 84 (4): 484-9.
[7] Ganigara M, Tanous D, Celermajer D, Puranik R. The role of cardiac MRI in the diagnosis and management of sinus venosus atrial septal defect. Ann Pediatr Cardiol. 2014; 7 (2): 160-2.
[8] Gertsvolf N, Andersen E, Othman T, et al. Patent foramen ovale and neurologic events in patients undergoing liver transplantation. Cardiovasc Revasc Med. 2018; 19: S53-55.
[9] Ghaemian A, Nabati M, Shokri M. Undiagnosed inferior vena cava type of sinus venosus atrial septal defect in a middle aged woman: a rare case report. J Clin Ultrasound. 2019; 1: 1-3.
[10] Goeddel LA, Jung YH, Patel P, Upchurch P, Fernando RJ, Ramakrishna H. Analysis of the 2018 American Heart Association/American College of Cardiology guidelines for the management of adults with congenital heart disease: implications for the cardiovascular anesthesiologist. J Cardiothorac Vasc Anesth. 2019.
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[12] Kijima Y, Akagi T, Takaya Y, et al. Deficient surrounding rims in patients undergoing transcatheter atrial septal defect closure. J Am Soc Echocardiogr. 2016; 29 (8): 768-76.
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[14] Ling L, He X, Zeng J, Liang Z. In-hospital cerebrovascular complications following orthotopic liver transplantation: a retrospective study. BMC Neurol. 2008; 8: 52.
[15] O’Sullivan CJ, Magarzo JG, Bernheim AM, Eberli F. Paradoxical embolism via a sinus venosus atrial septal defect causing an inferior ST-segment elevation myocardial infarction in a 23-year-old woman. BMJ Case Rep. 2016.
[16] Oliver JM, Gallego P, Gonzalez A, Dominguez FJ, Aroca A, Mesa JM. Sinus venosus syndrome: atrial septal defect or anomalous venous connection? A multiplane transoesophageal approach. Heart. 2002; 88 (6): 634-8.
[17] Olmedilla L, Garutti I, Perez-Pena J, Sanz J, Teigell E, Avallanal M. Fatal paradoxical air embolism during liver transplantation. Br J Anaesth. 2000; 84 (1): 112-4.
[18] Raval Z, Harinstein ME, Skaro AI, et al. Cardiovascular risk assessment of the liver transplant candidate. J Am Coll Cardiol. 2011; 58 (3): 223-31.
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Cite This Article
  • APA Style

    Annette Rebel, Lauren Hampton, Zaki-Udin Hassan, Malay Shah. (2021). The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report. Journal of Surgery, 9(4), 204-208. https://doi.org/10.11648/j.js.20210904.21

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    ACS Style

    Annette Rebel; Lauren Hampton; Zaki-Udin Hassan; Malay Shah. The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report. J. Surg. 2021, 9(4), 204-208. doi: 10.11648/j.js.20210904.21

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    AMA Style

    Annette Rebel, Lauren Hampton, Zaki-Udin Hassan, Malay Shah. The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report. J Surg. 2021;9(4):204-208. doi: 10.11648/j.js.20210904.21

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  • @article{10.11648/j.js.20210904.21,
      author = {Annette Rebel and Lauren Hampton and Zaki-Udin Hassan and Malay Shah},
      title = {The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report},
      journal = {Journal of Surgery},
      volume = {9},
      number = {4},
      pages = {204-208},
      doi = {10.11648/j.js.20210904.21},
      url = {https://doi.org/10.11648/j.js.20210904.21},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.js.20210904.21},
      abstract = {The case report discusses a significant discrepancy between the pre-transplant cardiac evaluation and post-induction transesophageal echocardiography, leading to aborting the surgical procedure. The transthoracic echocardiography [TTE] pre-liver transplant indicated only a minor intracardiac shunt, while the post-induction transesophageal echocardiography [TEE] showed a large atrial septal defect with a more significant left to right shunt. The attempt to close the defect with a transcatheter closure device failed and the perioperative care team decided not to proceed with the liver transplantation. Later cardiac evaluation with cardiac magnetic resonance imaging demonstrated a secundum atrial septum defect in the inferior border of the interatrial septum with 43 ml flow difference between systemic and pulmonary circulation. The failure to identify a large atrial septal defect/inferior venosus defect in the preoperative screening process for liver transplantation resulted in failing to optimize the patient pre transplant. Although complications related to large atrial septal defects are rare during liver transplant (paradoxical embolisms, malignant arrhythmias, myocardial infarctions or cerebrovascular complications), they can be potentially fatal. The preoperative cardiac assessment should have included optimization of this congenital defect. The case report discusses implications of atrial septal defects for liver transplant and why the screening process may have missed the defect. The findings of a positive bubble study during the transthoracic echocardiography should not be trivialized and may require further workup.},
     year = {2021}
    }
    

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    T1  - The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report
    AU  - Annette Rebel
    AU  - Lauren Hampton
    AU  - Zaki-Udin Hassan
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    DO  - 10.11648/j.js.20210904.21
    T2  - Journal of Surgery
    JF  - Journal of Surgery
    JO  - Journal of Surgery
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    PB  - Science Publishing Group
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    AB  - The case report discusses a significant discrepancy between the pre-transplant cardiac evaluation and post-induction transesophageal echocardiography, leading to aborting the surgical procedure. The transthoracic echocardiography [TTE] pre-liver transplant indicated only a minor intracardiac shunt, while the post-induction transesophageal echocardiography [TEE] showed a large atrial septal defect with a more significant left to right shunt. The attempt to close the defect with a transcatheter closure device failed and the perioperative care team decided not to proceed with the liver transplantation. Later cardiac evaluation with cardiac magnetic resonance imaging demonstrated a secundum atrial septum defect in the inferior border of the interatrial septum with 43 ml flow difference between systemic and pulmonary circulation. The failure to identify a large atrial septal defect/inferior venosus defect in the preoperative screening process for liver transplantation resulted in failing to optimize the patient pre transplant. Although complications related to large atrial septal defects are rare during liver transplant (paradoxical embolisms, malignant arrhythmias, myocardial infarctions or cerebrovascular complications), they can be potentially fatal. The preoperative cardiac assessment should have included optimization of this congenital defect. The case report discusses implications of atrial septal defects for liver transplant and why the screening process may have missed the defect. The findings of a positive bubble study during the transthoracic echocardiography should not be trivialized and may require further workup.
    VL  - 9
    IS  - 4
    ER  - 

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Author Information
  • Department of Anesthesiology, University of Kentucky, Lexington, Kentucky, USA

  • Department of Anesthesiology, University of Kentucky, Lexington, Kentucky, USA

  • Department of Anesthesiology, University of Kentucky, Lexington, Kentucky, USA

  • Department of Surgery, Division of Abdominal Transplant, University of Kentucky, Lexington, Kentucky, USA

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