What are the cardiac effects after liver retrieval?

From the Guidelines

After liver retrieval, the heart typically continues to function until it is either retrieved for transplantation or cardiac death occurs, with careful timing and coordination crucial to maintain organ viability. The sequence of organ retrieval is critical, with the liver usually being retrieved first, followed by the heart, to ensure optimal preservation of both organs 1. This approach is supported by recent studies, which highlight the importance of multidisciplinary management of cardiac diseases in liver transplant recipients, including optimizing metabolic syndrome and its components, as well as the use of newer diabetes medications with cardioprotective potential 1.

In the context of liver retrieval, the heart's function is closely monitored, and its continued beating is essential to maintain blood flow to other organs until the procurement process is complete. If the heart is not being retrieved, it will continue to beat until circulation is stopped at the end of the multi-organ procurement 1. The decision to perform a specific procedure, such as a transjugular intrahepatic portosystemic stent-shunt (TIPSS), should be made by a multidisciplinary team, taking into account the patient's cardiac risk profile and the potential impact on cardiac function 1.

Key considerations in the management of cardiac diseases in liver transplant recipients include:

• Optimizing metabolic syndrome and its components
• Using newer diabetes medications with cardioprotective potential
• Careful timing and coordination of organ retrieval to maintain viability
• Multidisciplinary management of cardiac diseases, including cardiac assessment and risk mitigation
• Consideration of the patient's cardiac risk profile when making decisions about procedures such as TIPSS 1.

From the Research

Hemodynamic Changes After Liver Retrieval

• The heart's behavior after retrieving the liver is closely related to the patient's hemodynamic status, which can be affected by various factors such as liver disease, infection, and mechanical ventilation 2.
• Studies have shown that patients with liver cirrhosis may develop symptoms comparable to those of patients with sepsis, including increased total vascular compliance, which can cause blood pooling in the venous pool 3.
• The use of norepinephrine in patients undergoing liver transplantation can increase mean arterial pressure, cardiac output, and systemic vascular resistance, which can have a positive effect on the heart's function 3.

Cardiac Output and Systemic Filling Pressure

• Research has demonstrated that norepinephrine infusion can increase cardiac output (CO) in patients with liver cirrhosis undergoing liver transplantation, primarily due to an increase in venous return caused by an increase in mean systemic filling pressure 3.
• The effect of norepinephrine on CO was found to be significant in 60% of patients, while 40% showed no changes in CO 3.
• The discontinuation of norepinephrine infusion was associated with a significant decrease in mean arterial pressure, CO, and systemic vascular resistance 3.

Renal Effects and Blood Pressure

• The optimal perioperative target mean arterial pressure (MAP) for renal filtration, perfusion, and oxygenation in liver recipients is not well established, but studies suggest that a target MAP of 75 mmHg may be optimal 4.
• Increasing MAP from 75 to 90 mmHg was found to increase renal vascular resistance, but had no further effects on cardiac index, renal blood flow, or glomerular filtration rate 4.
• The length of observation for nonoperative management of blunt liver injuries should be based solely on clinical criteria, and patients with liver injuries may be safely discharged home in the presence of a normal abdominal examination and stable hemoglobin, regardless of the grade of injury 5.