[Hemodynamics and hepatic transplantation using a veno-venous shunt: influence of the preoperative hyperkinetic...

The routine use of a veno-venous bypass is not accepted by all surgical liver transplantation teams. The putative benefits (maintaining haemodynamic stability during the anhepatic phase, reducing blood losses, avoiding renal failure) are counterbalanced by the real risks of air embolism or thromboembolism. A severe preclamping hyperkinetic haemodynamic status represents an elective indication for some authors, whilst it is a reduced cardiac function for others. Two groups of ten patients undergoing liver transplantation, with a porto-femoro-axillary venous bypass (flow rate 2 to 2.5 l.min-1), were studied retrospectively. They differed by their pre-clamping cardiac index (CI), greater than 5 l.min-1.m-2 in group A and less than 4.5 l.min-1.m-2 in group B. The same anaesthetic protocol was used in all patients consisting in fentanyl, thiopentone, pancuronium, and midazolam. The use of blood products and biological parameters did not differ between the two series of patients. The CI decreased by 30% and systemic vascular resistances (Rsa) increased by 48% in group A after clamping, without any deleterious effects on oxygen delivery; similarly, in group B, CI fell by 15% and Rsa increased by 20%. After unclamping, CI rose by greater than 50%, and Rsa decreased in both groups. No differences were seen between the two series 5 min after revascularisation. The release of vasoactive agents by the cold ischaemic graft could explain this. These results suggest that veno-venous bypass could be beneficial in the 2 different preoperative haemodynamic profiles studied. The low decrease in CI in hyperkinetic patients allowed tissue oxygenation to be maintained at adequate levels during the anhepatic phase.(ABSTRACT TRUNCATED AT 250 WORDS)