Persistent Severe Bradycardia During Liver Transplantation

Abstract

Abstract Background Cardiac electrophysiological disturbances are common in end-stage liver disease (ESLD) patients. It is challenging for anesthesiologists to detect and manage cardiac abnormalities during orthotopic liver transplantation (OLT). Case report A 58-year-old male patient, diagnosed with hepatitis B cirrhosis with hepatocellular carcinoma (MELD score 24) and chronic kidney disease stage V (no hemodialysis requirement), was scheduled for combined OLT with kidney transplantation. He had mild anemia, thrombocytopenia, normal electrolytes, and INR 1.47. CXR showed cardiomegaly with blunting of the bilateral costophrenic angle. ECG presented sinus bradycardia (rate, 45/min) with prolonged QT interval. Echocardiography revealed dilatation of all cardiac chambers with ejection fraction of 65%, good RV function, and mild pulmonary hypertension (mPAP, 29 mmHg) without significant valvular abnormality. After uneventful induction and intubation, noninvasive cardiac output monitoring and central venous catheter were applied. During surgery, his heart rate was 35–40 bpm with no response to high-dose inotropic agents. External cardiac pacing pads were attached. ABG showed mild acidosis without electrolyte abnormality. Reperfusion went successfully despite persistent severe bradycardia. He remained intubated and was transferred to the ICU. Twelve-lead ECG was performed. A cardiologist diagnosed cirrhotic cardiomyopathy with high vagal tone. Transvenous pacing was inserted at a rate of 80/min for 48 hours; his heart rate subsequently rose to 50–60 bpm without treatment. Extubation was 36 hours after surgery, and discharge on postoperative day 10 Conclusions Cardiac abnormalities in ESLD patients present in various forms. Proper preoperative assessment, adequate monitoring, and good team communication result in good patient outcomes