May’s Article of the Month, with commentary from Dr. Cara Crouch, examines a 9-year single-center retrospective from Mount Sinai on intracardiac thrombus (ICT) during liver transplantation — comparing incidence and outcomes before and after routine intraoperative TEE became standard practice. The findings make a strong case for TEE standardization: ICT was detected nearly twice as often in the TEE era, but 30-day mortality dropped substantially as earlier detection enabled treatment before hemodynamic collapse.
Key Findings
- Cohort: 1,176 adult liver transplants from 2011–2020, divided into pre-TEE (2011–2015; n = 491) and TEE era (2016–2020; n = 685)
- ICT incidence nearly doubled in the TEE era: 3.7% (25/685) vs. 1.9% (9/491); p < .001 — reflecting improved detection, not necessarily more events
- Pre-TEE era: 100% of ICTs presented as intraoperative cardiac arrest, with 30-day mortality of 66.7% (6/9)
- TEE era: 80% of ICTs were detected incidentally or during workup for hemodynamic instability (p = .002); 30-day mortality dropped to 36% (9/25)
- Patient-level associations with ICT: higher MELD-Na, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, prior DVT, reperfusion syndrome, platelet and cryoprecipitate transfusion, and hemostatic medication use
- Simultaneous liver-kidney recipients had a higher ICT rate — authors note this group also received more non-heparinized intraoperative RRT circuits, raising a possible mechanism
