Case reportDevastating intracardiac and aortic thrombosis: a case report of apparent catastrophic antiphospholipid syndrome during liver transplantation
Introduction
Fewer than 80 cases of intraoperative intracardiac and pulmonary thromboembolism have been described during liver transplantation [1]. The great majority of these cases involved the right heart. Thrombus formation in all cardiac chambers and aorta as a clinical manifestation of a catastrophic antiphospholipid syndrome is presented.
Section snippets
Case report
A 62 year old woman presented for liver transplantation secondary to decompensated cirrhotic liver disease [Model for End-Stage Liver Disease (MELD) score of 23] due to chronic hepatitis C. Preoperative evaluation showed significant hepatomegaly, splenomegaly, portal hypertension, mild renal insufficiency, and coagulopathy [prothrombin time (PT) of 16.9 sec, international normalized ratio (INR) of 1.7, platelet count of 55,000/μL]. Preoperative stress echocardiography indicated preserved left
Discussion
Antiphospholipid antibodies (aPL) are described as a family of autoantibodies directed against phospholipids and phospholipid-binding proteins. In low concentrations they are found in 1% to 5% of the general population, and they are more prevalent in elderly and chronically ill patients. Although these antibodies may prolong phospholipid-dependent reactions in in vitro coagulation assays (most often partial thromboplastin time) and interfere with both procoagulation and anticoagulation
Acknowledgments
Our thanks to Dr. David Lubarsky, MD, MBA, Emanuel M. Papper Professor and Chair, Department of Anesthesiology UM Miller School of Medicine; and Dr. Paul Martin, MD, FACP, Professor of Medicine, Chief, Division of Hepatology, University of Miami Miller School of Medicine, for their valuable suggestions in review of this manuscript.
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2018, Journal of Clinical AnesthesiaCitation Excerpt :It is also plausible that the balance of all the arms of the coagulation cascade - procoagulant, anticoagulant, fibrinolytic, anti-fibrinolytic and anti-antifibrinolytic – continuously shifts with the progression of ESLD and ESLD-associated (and still poorly understood) inflammatory processes. These shifts may be significantly accelerated intraoperatively so that even point-of-care viscoelastic monitoring may not be sensitive enough to neither forewarn of impending devastating thromboembolic event, nor to reflect rapid thrombolysis of intracardiac thrombus seen in survivors [15–17]. Our data indicate that diabetes mellitus may be associated with increased risks of postoperative 24-hour mortality after devastating ICPTE.
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2013, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :Hepatic infarction is a rare entity thanks to the dual blood supply to the liver; nevertheless, several cases of hepatic infarction have been reported in association with aPL [28]. aPL positivity has also been linked to hepatic artery thrombosis, a main cause of graft loss and patient mortality after liver transplantation [29,30]. There is not a uniformity of thinking about the necessity of screening for aPL in the pre-transplant workup.
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