Abstract P3013: Rare Case Of Catheter-related Right Atrial Thrombosis In A Pediatric Multi-visceral Transplant Patient

Abstract

Introduction: There has been a recent increase in the use of intraoperative transesophageal echocardiography (TEE) in liver transplant surgeries to identify intracardiac thrombi and pulmonary embolism (PE). These are rare but serious complications of transplant surgery that carry a high mortality risk. However, there is a lack of literature supporting the use of TEE during liver transplants, especially in pediatric cases. Case Presentation: We present a rare case of intraoperative catheter-related right atrial thrombus (CRAT) in a nine-year-old multi-visceral transplant (MVT) patient. This patient’s medical history was notable for preterm birth and gastroschisis complicated by neonatal necrotizing enterocolitis resulting in short-gut syndrome. He had a significant surgical history, including intestinal resection, Hartmann Procedure, and cholecystectomy, after which he developed non-cholestatic liver disease. He was admitted for MVT for intestinal failure associated with ESLD. The procedure was complicated by massive hemorrhage during the dissection phase, significant coagulopathy after engrafting the donor liver, profound hemodynamic instability requiring inotropic drug support, and multiple instances of intraoperative CPR. Intraoperative TEE identified right atrial thrombi around the central venous line. The patient developed RV dysfunction and PEA secondary to PE on two occasions and received a total of 4 mg tissue plasminogen activator (tPA). In both cases, ROSC was achieved after thrombolysis. Due to profound coagulopathy and massive blood loss (70 liters), the completion of the surgery was postponed, and the patient left the operating room with an open abdomen. The patient’s postoperative course was complicated by hemodiafiltration, ureteral resection with reimplantation to bladder, pyloroplasty, appendectomy, small bowel resection, end colostomy and double-barrel ileostomy. The patient eventually developed a subarachnoid hemorrhage on POD3 and expired. Conclusion: This case highlights the importance of utilizing intraoperative TEE in pediatric liver transplant surgeries to diagnose intracardiac thrombi and PE.