Inflow Obstruction Research Articles

Эректильная дисфункция: современное состояние проблемы, методы диагностики и рентгенэндохирургического лечения

According to the Russian Society of Urologists, almost half of men aged 27 to 77 suffer from erectile dysfunction. ED should be considered not only as a medical nosology, but also as a socio-psychological problem with a demographic aspect. There are many methodsfor improving erectile function, including psychological consultations, drug therapy and penile prosthetics. Given the accumulated international experience,the key pointis an accurate diagnosis ofthe cause of erectile dysfunction to determine the correct approach to treatment. Among the many causes of erectile dysfunction, vascular causes are quite common. Given the rapid development of endovascular and low-traumatic approachesto vascular pathology,the technique of improving inflow and outflow obstruction in vasculogenic erectile dysfunction is becoming increasingly obvious and effective. The presented article discussesthe currentstate ofthe issue and possible prospectsfor endovascularsurgery for vascular erectile dysfunction, including significant venous leakage.

Large ventricular myxoma causing inflow and outflow obstruction of the right ventricle; A Case Report

BackgroundMyxomas are the most common primary benign heart tumors, typically found in the left atrium, with only 2–4% occurring in the right ventricle. Clinical presentations vary widely, including congestive heart failure and systemic embolic phenomena. This case report describes a rare right ventricular myxoma causing both inflow and outflow obstruction, presenting as progressive exertional dyspnea.Case PresentationA 23-year-old male presented with two weeks of worsening exertional dyspnea. He was stable but tachypneic with a systolic murmur over the tricuspid area. Elevated erythrocyte sedimentation rate (ESR) and C-Reactive protein (CRP) were noted, while other lab tests were normal. Imaging, including echocardiography and chest tomography scan (CT) revealed a 4 × 3.8 × 4.6 cm mass in the right ventricle extending to the pulmonary trunk. Surgical resection via right ventriculotomy was performed, and histopathology confirmed myxoma. The patient recovered uneventfully.ConclusionRight ventricular myxomas, though rare, can cause significant obstruction and present with diverse symptoms. Timely diagnosis using imaging techniques like echocardiography is crucial. Surgical resection remains the definitive treatment, offering excellent outcomes and low recurrence rates. Early intervention is vital to prevent serious complications and ensure favorable patient prognosis.

408. IS DYSPNOEA IN PARAOESOPHAGEAL HERNIA ONLY POST PRANDIAL? RELEVANCE TO THE POST TOOL DEVELOPMENT

Abstract Background Paraoesophageal hernia (POH) presents with a unique symptomatology that may mimic respiratory and cardiovascular disease. Dyspnoea is increasingly recognised as a predominant symptom of POH. Post-prandial dyspnoea was included in a POH specific symptom reporting tool (POST). We have prospectively recorded the type of dyspnoea among patients with POH, and whether surgery improves dyspnoea. Methods Consecutive patients with POH managed in our service from 2009 to 2022 were identified. Preoperative dyspnoea was documented as 'post prandial' or 'with ordinary physical activity' on a symptom recording proforma. Post operative improvement in dyspnoea was evaluated. Results A total of 520 consecutive patients were diagnosed with POH between January 2009 to November 2022. 514 patients were included in the analysis; there were 383 females (75%) and mean age was 70. Improvement in dyspnoea was reported in 308 out of 355 (95%) patients. Pre-operative dyspnoea was categorised into activity induced (89%) and post-prandial (3%) or both (8%). Patients with both activity induced and post-prandial dyspnoea were 0.26 times less likely to report improvement in dyspnoea postoperatively than those with only activity induced dyspnoea (OR=0.26, 95% CI 0.07-0.94, P=0.041). Conclusion Symptom assessment of POH should include both post-prandial and activity induced dyspnoea, as both type of dyspnoea are associated with the presence of POH and is improved following surgical repair. There are multiple possible causes for dyspnoea including post prandial cardiac inflow obstruction, pulmonary aspiration, as well as anaemia (with or without iron deficiency) associated with the hernia. Any dyspnoea should be considered related to POH and therefore both post-prandial and activity induced dyspnoea should be included in diagnostic algorithm designed to evaluate POH.

Clinical presentation and surgical outcomes in patients with Shone's complex: a systematic review.

Shone's complex comprises ofa combination of congenital cardiac anomalies causing obstructions in the left ventricle's inflow and outflow tracts. This systematic review aims to evaluate the clinical features and surgical outcomes of Shone's complex. An electronic literature search of PubMed and Scopus was performed to identify relevant studies related to the presentation, management, and outcomes of Shone's complex. Two reviewers independently performed selection. Data on study characteristics, participant demographics, interventions, outcomes, and follow-up durations were extracted and analyzed. A total of 691 papers were identified, with 18 studies included in the final analysis. The majority of the studies (n = 12) focused on the pediatric age group. The most common clinical presentations were coarctation of the aorta (n = 17) and mitral stenosis (n = 12). Surgical interventions often involved staged approaches, prioritizing outflow before inflow obstructions. Mitral valve repair was preferred over replacement due to better long-term outcomes (n = 8). Biventricular repair was recommended due to improved postoperative outcomes, but often needed reoperations. Reoperations were common, primarily due to recurrent coarctation (n = 10), subaortic stenosis (n = 8), and mitral valve dysfunction (n = 7). Pulmonary hypertension (n = 10) and arrhythmias (n = 11) were significant complications. Most patients were in modified Ross/NYHA functional class 1 on follow-up. Mortality rates ranged from 4 to 28%, with better outcomes associated with early and strategic surgical interventions. Early diagnosis and biventricular repair were associated with better outcomes while transplantation was often an eventuality. Standardized diagnostic criteria, long-term follow-up, and consensus guidelines are needed to improve the management of this congenital heart disease.

Use of venoarterial extracorporeal membrane oxygenation to bypass right-sided cardiac inflow obstruction

Use of venoarterial extracorporeal membrane oxygenation to bypass right-sided cardiac inflow obstruction

Perioperative and Anesthetic Considerations in Shone's Complex.

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Left Ventricular Assist Device Pump Obstruction Reduces Native Heart Efficiency.

Obstruction of the LVAD flow path can occur when blood clots or tissue overgrowth form within the inflow cannula, pump body, or outflow graft, and it can lead to thrombus, embolism, and stroke. The goal of this study was to measure the impact of progressive pump inflow obstruction on the pressure and flow dynamics of the LVAD-supported heart using a mock circulatory loop. Pump obstruction (PO) was produced by progressively blocking a fraction of the LVAD inlet area. Pressures, flows, and the midplane velocity field of the LV were measured for three LVAD speeds and six PO levels. Pressure and flow decreased with PO, shifting more of the flow through the aortic valve such that the total flow decreased by 6-11% and decreased the efficiency of the work of the native heart up to 60%. PO restricts diastolic flow through the LVAD, which reduces mitral inflow and decreases the strength and energy of the intraventricular vortices. The changes in flow architecture produced by PO include flow stasis and increased shear, which predispose the system to thromboembolic risk. Analysis of the contributions to external work may enable early detection, which allows time for therapeutic intervention, reducing the likelihood of pump replacement and the risk of complications.

Abstract 16777: Do Not Clown Around With Intracardiac Myxomas: A Clinical Case of Carney Complex

Introduction: Intracardiac myxomas are associated with cardiovascular mortality most frequently due to embolism and obstruction leading to heart failure. One of the most feared complications of intracardiac myxomas are sudden cardiac death, as these tumors are often identified incidentally. Carney Complex (CNC) is a rare disorder characterized by cardiac myxomas, psammomatous melanotic schwannomas, abnormal skin pigmentation, and endocrine disorders. Clinical Case: A 55 year old female with a past medical history of hypertension presented to the hospital with syncopal episodes and intermittent vision loss. Head computed tomography scan noted a large extra-axial mass present within the left cerebellopontine angle. A transthoracic echocardiogram showed a severely dilated left atria containing a large atrial mass (7.9 x 5.0 cm) that was causing obstruction of mitral inflow resulting in peak velocity 246 cm/S with a mean gradient of 12 mmHg. The patient was also noted to have dispersed epithelioid blue nevi present on skin examination. The patient met major criteria for diagnosis of Carney Complex. Conclusion: Carney complex (CNC) is an extremely rare autosomal dominant syndrome with less than 1,000 cases reported worldwide. Patients with familial history of intracardiac myxomas, multiple myxomas, characteristic skin findings, or endocrinopathies should be evaluated for CNC. Patients with cardiac myxoma secondary to CNC typically have a recurrence risk of roughly 30%. Patients with CNC should be screened with biannual transthoracic echocardiograms after resection and patients with suspected CNC should be worked up for additional tumor burden and endocrinopathies.

Discussion to: Chronic in utero mitral inflow obstruction unloads left ventricular volume in a novel late gestation fetal lamb model

Discussion to: Chronic in utero mitral inflow obstruction unloads left ventricular volume in a novel late gestation fetal lamb model

Chronic in utero mitral inflow obstruction unloads left ventricular volume in a novel late gestation fetal lamb model

ObjectiveThe in utero no flow/no grow hypothesis postulates that reduced inflow of blood into the left ventricle due to a stenotic mitral valve could lead to ventricular hypoplasia and hypoplastic left heart syndrome. This has been demonstrated in chick embryos, but less so in large animals. We investigated the impact of mitral obstruction on left and right ventricular growth in fetal lambs. MethodsTwelve pregnant ewes, most bearing twins, were instrumented at 119 ± 1 days gestational age. Carotid artery and jugular vein catheters, an ascending aorta flow probe, and a left atrial deflated balloon catheter were implanted into 1 fetus (left atrial balloon group), and the twin remained an uninstrumented control. The balloon was inflated gradually over 8 days until net antegrade aortic flow was eliminated. Fetal transesophageal echocardiography was performed at the time of surgery and just before termination in both groups. ResultsTerminal fetal body weights were comparable between groups. Terminal heart/body weight ratio was higher in left atrial balloon group fetuses (6.9 ± 0.8 g/kg) compared with controls (5.9 ± 0.6 g, P = .0126). The left ventricular/right ventricular weight ratio was 24% (P = .0077) lower in left atrial balloon group fetuses than in controls. Left ventricular/heart weight (0.24 ± 0.04 g/g vs 0.30 ± 0.04 g/g, P = .0009), left ventricular end-diastolic volume (2.3 ± 0.7 mL vs 7.1 ± 0.8 mL; P = .0012), and left ventricular end-systolic volume (1.01 mL [0.95-1.95 mL] vs 3.38 mL [3.28-3.57 mL], P = .0042) were lower in left atrial balloon group fetuses compared with controls. Right ventricular weight (g/kg), right ventricular end-diastolic volume, and right ventricular end-systolic volume were similar between groups. ConclusionsIn this late-gestation fetal lamb model, in utero obstruction of mitral inflow slowed left ventricular growth and caused right ventricular remodeling.

Surgical Considerations in Shone Complex.

Shone complex is defined by 4 anomalies: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and coarctation of the aorta. Establishing a clear definition is one of the principal challenges in the study of Shone complex as not all patients have all lesions. The essential feature of Shone complex is multilevel left-sided obstruction involving both the left ventricular inflow and outflow. This anatomic variability is reflected in the clinical presentation as signs of left ventricular inflow obstruction are often masked by outflow obstruction and the multilevel nature of the condition is thus underappreciated. Surgical treatment is often stepwise addressing the outflow obstruction first. In this review, geared to the pediatric cardiac anesthesiologist, we review the pathophysiology, diagnosis, treatment, and outcomes of Shone complex.

Decreased left heart flow in fetal lambs causes left heart hypoplasia and pro-fibrotic tissue remodeling

Low blood flow through the fetal left heart is often conjectured as an etiology for hypoplastic left heart syndrome (HLHS). To investigate if a decrease in left heart flow results in growth failure, we generate left ventricular inflow obstruction (LVIO) in mid-gestation fetal lambs by implanting coils in their left atrium using an ultrasound-guided percutaneous technique. Significant LVIO recapitulates important clinical features of HLHS: decreased antegrade aortic valve flow, compensatory retrograde perfusion of the brain and ascending aorta (AAo) from the arterial duct, severe left heart hypoplasia, a non-apex forming LV, and a thickened endocardial layer. The hypoplastic AAo have miRNA-gene pairs annotating to cell proliferation that are inversely differentially expressed by bulk RNA-seq. Single-nucleus RNA-seq of the hypoplastic LV myocardium shows an increase in fibroblasts with a reciprocal decrease in cardiomyocyte nuclei proportions. Fibroblasts, cardiomyocytes and endothelial cells from hypoplastic myocardium have increased expression of extracellular matrix component or fibrosis genes with dysregulated fibroblast growth factor signaling. Hence, a severe sustained ( ~ 1/3 gestation) reduction in fetal left heart flow is sufficient to cause left heart hypoplasia. This is accompanied by changes in cellular composition and gene expression consistent with a pro-fibrotic environment and aberrant induction of mesenchymal programs.

An Unusual Presentation of a Rare Case of Rhabdomyosarcoma of the Left Atrium as Severe Rheumatic Mitral Stenosis with Atrial Fibrillation, Fast Ventricular Rate, and Left Atrial Failure

It is extremely rare to encounter primary malignant tumors of the heart. Rhabdomyoma constitutes approximately 20% of all primary malignant tumors of the heart. Rhabdomyoma commonly arises from the ventricular wall, and rarely, they arise from the atrial wall and mimic symptomatic atrioventricular valve stenosis. We describe an extremely rare case of left atrial (LA) rhabdomyosarcoma detected during the transesophageal echocardiography arising from the posterior wall of the left atrium protruding into the left ventricle causing obstruction of the mitral valve. Our case is a rare case of LA rhabdomyosarcoma presenting with mitral inflow obstruction and symptomatically mimicking severe rheumatic mitral stenosis with atrial fibrillation and fast ventricular rate with orthopnea secondary to LA failure and passive pulmonary venous congestion.

P270 THE IMPORTANCE OF INTEGRATED IMAGING IN THE DIFFICULT DIFFERENTIAL DIAGNOSIS OF A LEFT INTRACARDIAC MASS IN YOUNG ADULT

Abstract The patient is a 34–year–old man who comes to the emergency room with mild hemoptysis, asthenia, low–grade fever, night sweats and weight loss. Cardiac auscultation reveals a diastolic murmur at the cardiac apex. Transthoracic and transesophageal echocardiograms are performed and show an isoechoic thickening encompassing the posterior leaflet, cranially involving the atrial septum and the lateral wall up to the inlet of the left atrial appendage and inferiorly involveing the subvalvular apparatus with diffuse thickening and chordal fusion. Functionally it determines a moderate mitral stenosis with an average gradient of 10 mmHg and a valve area of ​​1.1 cm2 and a mild–moderate regurgitation with an anteriorly directed eccentric jet. At this point we needed to make the differential diagnosis considering as possible etiologies infective endocardic vegetation, thrombosis, primary and secondary neoplasms, aseptic vegetation and inflammatory or rheumatic valvulitis. We therefore begin our diagnostic work–up by performing a scintigraphy with labeled leukocytes, which does not show the presence of hyperuptake areas referable to infective endocarditis, and a PET scan which shows, in addition to the increased uptake at the cardiac level, an area of ​​greater concentration of the metabolic tracer in the gastric area (between the body and the fundus). Given the confirmation of metabolically active tissue, the patient performed cardiac magnetic resonance with contrast medium which confirmed the presence of pathological tissue with inhomogeneous late post–contrast enhancement. After collegial discussion, due to the high risk of biopsy of the mitral lesion, which was poorly separable from the cardiac structures, given the other localization of the disease at the gastric level, it was decided to perform an EGDS with relief of an ulcerated lesion on the gastric fundus which is subjected to biopsy and histological typing. We then arrive at the diagnosis of “undifferentiated pleomorphic sarcoma”. Sarcoma is the most frequent histological type of primary malignant cardiac tumors. The clinic is characterized by constitutional symptoms, obstruction of the valve inflow or outflow tract, thromboembolism, and arrhythmias. It has a poor prognosis: 6–12 months from diagnosis. In conclusion, we reiterate the importance of integrated imaging to arrive at the final diagnosis, each method with a specific objective.

Detection of inflow obstruction in left ventricular assist devices by accelerometer: A porcine model study

Left ventricular assist devices (LVAD) provide circulatory blood pump support for severe heart failure patients. Pump inflow obstructions may lead to stroke and pump malfunction. We aimed to verify in vivo that gradual inflow obstructions, representing prepump thrombosis, are detectable by a pump-attached accelerometer, where the routine use of pump power (PLVAD) is deficient. In a porcine model (n=8), balloon-tipped catheters obstructed HVAD™ inflow conduits by 34%-94% in five levels. Afterload increases and speed alterations were conducted as controls. We computed nonharmonic amplitudes (NHA) of pump vibrations captured by the accelerometer for the analysis. Changes in NHA and PLVAD were tested by a pairwise nonparametric statistical test. Detection sensitivities and specificities were investigated by receiver operating characteristics with areas under the curves (AUC). NHA remained marginally affected during control interventions, unlike PLVAD. NHA elevated during obstructions within 52-83%, while mass pendulation was most pronounced. Meanwhile, PLVAD changed far less. Increased pump speeds tended to amplify the NHA elevations. The corresponding AUC was 0.85-1.00 for NHA and 0.35-0.73 for PLVAD. Elevated NHA provides a reliable indication of subclinical gradual inflow obstructions. The accelerometer can potentially supplement PLVAD for earlier warnings and localization of pump thrombosis.

Pericardial Patch Aneurysm following Repair of Atrioventricular Septal Defect and Mitral Valve Replacement with 10-Year Follow-Up

A 26-year-old female patient who had surgical closure of the ventricular septal defect with an autologous pericardial patch and mitral valve repair for the cleft mitral valve in early childhood at age 4 and then subsequently mitral valve replacement with a bioprosthetic valve in 2011 at the age of 16 years, was found to have a large cystic mass protruding into the right ventricular inflow on echocardiography during a late routine examination in 2012. The cystic mass identified on echocardiography was shown to be an aneurysmal dilatation of the autologous pericardial patch used for the repair of the ventricular septal defect. As the third corrective surgery would have been inherently complicated with risk to the conduction system, she has been followed conservatively for the last 10 years without any significant complaints except mild dyspnea. This case illustrates that the pericardial patch aneurysm is relatively stable and surgery is rarely indicated unless the aneurysm causes mechanical compression or obstruction of the right ventricular inflow or outflow.

Detection of inflow obstruction in left ventricular assist devices by accelerometer: An in vitro study

Inflow obstruction in left ventricular assist devices (LVAD) may lead to embolic stroke and pump malfunction. We investigated if an accelerometer detected graded LVAD inflow obstructions. Detection performances were compared to the current continuous surveillance routine based on the pump power consumption (PLVAD). In ten mock circuit experiments, four different-sized pendulating balloons obstructed HVAD™ inflow conduits cross-section areas by 14%-75%. Nonharmonic amplitudes (NHA) of continuous signals from a triaxial accelerometer attached to the LVAD were compared against single-point PLVAD values, using load and speed alterations as control interventions. We analyzed the NHA band power with a pairwise nonparametric statistical test. The detection performances were analyzed by receiver operating characteristics with areas under the curves (AUC). The NHA remained unaffected during load alterations. In contrast, NHA increased significantly from the 27% obstruction level (AUC≥0.82), an effect amplified by increased pump speed. PLVAD did not change significantly below the maximal 75% obstruction level (AUC≤0.36). In conclusion, NHA detected the inflow obstructions much better than PLVAD. The technique may provide a future monitoring modality of any pendulating obstructive inflow pathology.

Biofunctional impact of textured coatings in the application of heart assist therapy

Due to a lack of organs, cardiac support systems are being implanted in patients with severe congestive heart failure. One of the solutions to overcome complications such as inflow obstruction or pump thrombosis, which may occur in the case of ventricular assist devices, is to modify the surface of cannulas for the controlled blood clotting process. The results obtained up till now for developed surface coatings clearly show the influence of topographical and mechanical parameters of the coatings on cell viability and protein adsorption mechanism. The new coatings should enable the controlled growth of scar tissue, resulting in the limitation of thromboembolic events, and the reduction of cystic tissue growth into the flow lumen. The aim of this study is to evaluate the correlation between surface topography parameters on the susceptibility of cells to grow and adhere to the substrate as a solution with potential for use in MCS (mechanical circulatory support) devices. Research on surfaces used in MCS devices and on inflow cannulas has been carried out for many years, while the novelty of the present solution makes it a milestone within that type of application simultaneously allowing for appropriate selection of process parameters. Surface modification of titanium alloy Ti6Al7Nb was carried out using vacuum powder sintering of CP-Ti (commercially pure titanium) powder with two morphologies (regular spheres and irregular grains). The characterization of coatings obtained with the proposed method and the influence of measured topographic parameters (applying scanning electron microscopy, contact angle measurement and contact profilometry) on the cytotoxicity and susceptibility to protein adsorption were presented. Advanced albumin adsorption studies have fully confirmed the dependence of surface complexity on protein adsorption. The obtained results show a high potential of the produced coatings toward enabling permanent integration at the implant with the soft tissue.

Abstract 13151: Left Ventricular Hypovolemia Secondary to in Utero Mitral Valve Inflow Obstruction in a Late-Gestation Fetal Lamb Model

Introduction: Hypoplastic left heart syndrome (HLHS) is a congenital heart defect of an underdeveloped left ventricle (LV), necessitating palliative interventions after birth to survive. HLHS often occurs alongside mitral or aortic valve stenosis, lending to the hypothesis that reduced blood flow into and out of the LV in utero could retard LV growth. We have developed a late-gestation fetal lamb model to investigate if in utero mitral inflow obstruction could cause LV hypovolemia. Methods: Twelve pregnant ewes with twin fetuses at 82% gestation were used. In the experimental fetuses (EXPT), mitral inflow obstruction was achieved with an inflatable balloon catheter implanted into the left atrium (LA) in a beating heart. Other implants included a flow probe on the ascending aorta to measure cardiac output, and carotid artery and jugular vein catheters to monitor fetal health. After recovery from surgery, progressive LA balloon inflation began at ~86% gestation, and was left inflated for 8 days (92% gestation). Transesophageal fetal ultrasound was performed at baseline and at termination to measure cardiac chamber volumes and function. Hearts were explanted, weighed and prepared for histology. Results: Fetal body weights were similar (EXPT: 4.6±0.9kg vs CTRL: 4.5±0.6kg, p=0.8597). Total heart weight was higher in EXPT (31.4±5.6g) than CTRL (26.4±2.4g, p=0.0471), but LV weight was similar (EXPT: 7.4± 1.8g vs. CTRL: 7.9± 1.1g, p=0.5652). LV end-diastolic volume was 2.3± 0.7ml in EXPT vs. 7.1± 0.8ml in CTRL (p<0.0001), and end-systolic volume was 1.01ml (0.95 to 1.95ml) in EXPT vs. 3.38ml (3.28 to 3.57ml) in CTRL (p=0.0025). LV/RV weight ratio was 0.83±0.17 in EXPT and 1.08±0.19 in CTRL (p=0.0209), whereas LV/RV chamber area ratio was 0.21±0.06 in EXPT and 0.56±0.05 in CTRL (p=0.0005). Conclusions: In this fetal sheep model, obstructing mitral inflow retarded LV growth, demonstrating a potential mechanistic link between blood inflow and in utero LV volumetric growth.

Massive duodenal ulcer bleeding due to the ruptured hepatic artery pseudoaneurysm after living donor liver transplantation

BackgroundThe rupture of a hepatic artery pseudoaneurysm (HAP) is a rare but lethal complication after living donor liver transplantation (LDLT) and often manifests as acute gastrointestinal bleeding.Case presentationThis report describes three patients who experienced HAP after LDLT. These patients initially presented with active bleeding of a duodenal ulcer (DU) in the duodenal bulb, followed by diagnosis of the ruptured HAP by angiography. None of the patients had evidence of an active intra-abdominal infection or bile leakage preceding the rupture of HAP. All patients were initially treated by transcatheter arterial coil embolization (TAE). In all cases, TAE was successful for hemostasis but resulted in complete obstruction of the arterial inflow to the graft. Arterial revascularization by surgical reconstruction using the autologous arterial graft in one case and re-LDLT in another one was successfully performed. The other one succumbed to sepsis caused by later liver abscesses.ConclusionThis is the first detailed case series of massive DU bleeding as a warning signal of ruptured HAP after LDLT. HAP should be included in the differential diagnosis when an LDLT recipient presents with gastrointestinal bleeding.