Citations 1
Intracardiac thrombosis and its management during liver transplantation: international, multicenter, case-control study
Prete, Luca Del , Cazzaniga, Beatrice , Aniskevich, Stephen , Agopian, Vatche G. , Smith, Natalie , Cacioppo, Brian J, Nuti, Anna Maria, Wang, Ryan , Gamboa, Bs Sophia, Groose, Molly K. , Sheth, Mansi, Cywiński, Jacek B. , Wray, Christopher , Hashimoto, Koji , Liu, Qiang , Quintini, Cristiano , Del Prete, Luca , Agopian, Vatche G , Smith, Natalie K , Tu, Chao , Groose, Molly K , Cywinski, Jacek B , Nguyen-Buckley, Christine , Florman, Sander S , Liu, Qiang , Ekser, Burcin , Aniskevich, Stephen , Cacioppo, Brian J., Watson, Christopher, Pai, Sher‐Lu , Nguyen, Christine , Florman, Sander , Croome, Kristopher P. , Ekser, Burcin
International Journal of Surgery | August 22, 2025 | Volume: 111 | Issue: 12 | Pages: 8793-8805
Background: Intracardiac thrombosis (ICT) during liver transplantation (LT) is a rare but life-threatening complication with limited data regarding its risk factors, management, and outcomes. This study aimed to identify factors associated with ICT development, define predictors of intraoperative outcomes, and propose a novel classification and management algorithm for ICT. Methods: A multicenter, international retrospective case-control study was conducted on liver transplant recipients from seven centers between January 2005 and December 2023. ICT cases were identified through transesophageal echocardiography (TEE) or autopsy and matched 1:1 with controls. Results: Among 11 077 liver transplant recipients screened, 133 patients (1.2%) developed ICT. ICT occurred predominantly after reperfusion (58%). Compared to controls, ICT cases exhibited higher preoperative international normalized ratio ( P = 0.001) and fibrinogen levels ( P = 0.014). Post-reperfusion syndrome ( P < 0.001), disseminated intravascular coagulation ( P < 0.001), and primary graft failure ( P = 0.002) were also more common in the ICT group. Continuous veno-venous hemofiltration during surgery (odds ratio [OR] 8.20, 95% confidence interval [CI]: 2.09–38.1; P = 0.004) was associated with ICT development. ICT was associated with markedly higher rates of cardiac arrest ( P < 0.001) and intraoperative mortality ( P < 0.001), with thrombus location in the left heart chambers representing a significant predictor of mortality (OR 20.7, 95% CI: 6.25–81.3; P < 0.001). ICT grades 2 and 3 were associated with a markedly increased risk of intraoperative cardiac arrest ( P < 0.05). Importantly, delayed use of TEE was strongly associated with intraoperative death (OR 6.27, 95% CI: 1.45–27.1; P = 0.014). The 90-day mortality was 43% in ICT cases compared to 4.5% in controls, while 1-year mortality was 46% versus 10.5%, respectively. Conclusions: ICT during LT is a rare but severe complication associated with intraoperative mortality and poor short-term survival. Coagulation profile and intraoperative management play critical roles in ICT development. The early use of TEE enables timely diagnosis and intervention, improving patient outcomes. We propose a novel ICT classification offering a systematic framework for risk stratification and management to mitigate progression and mortality.