Risk factors associated with acute heart failure during liver transplant surgery: a case control study

Acute intraoperative heart failure (HF) is a rare but often fatal complication of liver transplant surgery. Little is known about the clinical course or predictive variables. Our aims were to provide a detailed clinical description and conduct a systematic search for characteristics associated with intraoperative HF.

A matched case-control study of adults undergoing primary liver transplant from 2009 to 2011 was conducted. Cases showed new onset HF with an ejection fraction less than 50% during liver transplant surgery. Controls were recipients without signs or symptoms of HF. Matching was based on: age, sex, model for end-stage liver disease at the time of transplant, type 2 diabetes, and β-blocker use. Conditional logistic regression analyses were conducted.

From 2009 to 2011, seven (3%) of 256 recipients developed intraoperative HF with one resulting death. All survivors regained normal systolic function within 6 months of surgery. Decreasing preoperative serum sodium (odds ratio, 1.41; 95% confidence interval, 1.02-1.94; P = 0.039) and increasing number of units of packed red blood cells transfused intraoperatively (odds ratio=1.2, 95% confidence interval, 1.001-1.467, P = 0.048) were associated with HF.

No preoperative echocardiographic parameter predicted HF in affected patients. Two possible explanations are: our patients suffered from stress cardiomyopathy and therefore had no evidence of impaired contraction before the event or echocardiographic predictors of HF were masked by circulatory changes in patients with cirrhosis. Lower serum sodium and more red blood cell transfusions were associated with intraoperative HF. Lower mortality of our intraoperative cases compared to others may be influenced by earlier diagnosis and intervention.