A Focused Transesophageal Echocardiography Protocol for Intraoperative Management During Orthotopic Liver Transplantation

Abstract

Objective: The value of a simplified, focused intraoperative transesophageal echocardiography (TEE) protocol in patients undergoing liver transplantation (LT) is unknown. We sought to create and assess a 5-view LT TEE examination focused on 5 prespecified common causes of hypotension during LT.

Design: Retrospective cohort study.

Setting: Single-center tertiary academic hospital.

Participants: All patients undergoing LT with TEE from January 2010 through May 2019.

Interventions: None.

Measurements and main results: A 5-view LT TEE protocol adapted from a published rescue TEE protocol was assessed retrospectively in a cohort of 106 patients. The primary outcome was the frequency with which the protocol would have detected a composite of 5 prespecified causes of hypotension if the TEE exam had been limited to those views. To assess potential influence on intraoperative care, management changes associated with TEE images were extracted from the medical record. The prespecified diagnoses occurred 24 times; the LT TEE protocol would have detected 22 of 24 of these (92%, 95% confidence interval [CI]: 74%-98%). Intraoperative management changes occurred in 15 of 16 patients (94%) with 1 of the prespecified TEE findings, compared with 1 of 27 patients (3.7%) with TEE findings outside those diagnoses (p < 0.0001).

Conclusions: In a retrospective cohort study, a simplified LT TEE protocol would have detected 92% of prespecified TEE findings. Management changes occurred in 94% of those patients, while changes rarely occurred in patients with other TEE findings. A focused LT TEE protocol may diagnose critical pathology adequately and guide management during LT when standard monitors are insufficient.

Keywords: hemodynamic instability; intraoperative hypotension; liver transplant; monitoring echocardiography; rescue echocardiography; transesophageal echocardiography.