What is the best approach for a patient with liver transplant failure, hypokinesia of the anterior wall on 2D echo, and deep vein thrombosis (DVT) for fitness for liver transplant surgery?

Management of a Post-Liver Transplant Patient with DVT for Retransplantation Fitness

For a patient with liver transplant failure, anterior wall hypokinesia on echocardiogram, and recent deep vein thrombosis (DVT), anticoagulation should be continued while proceeding with cardiac risk stratification prior to liver retransplantation.

Cardiac Evaluation for Liver Retransplantation

Initial Assessment

• Review the 2D echo findings carefully:
  • Quantify the extent of anterior wall hypokinesia
  • Confirm that LV function is truly adequate (EF ≥50%)
  • Look for other structural abnormalities (valvular disease, pulmonary hypertension)

Recommended Cardiac Testing

1. Stress Testing:

   • Pharmacological stress test (dobutamine stress echo or nuclear perfusion imaging) to evaluate the functional significance of the anterior wall hypokinesia
   • Avoid exercise stress testing due to deconditioning in end-stage liver disease

2. Coronary Evaluation:

   • Consider coronary angiography if:
     • Stress test shows inducible ischemia
     • Patient has multiple cardiac risk factors (diabetes, hypertension, smoking history)
     • The anterior wall hypokinesia is moderate to severe

DVT Management

Anticoagulation Approach

• Continue anticoagulation for the recent DVT (diagnosed 10 days ago) 1
• Choice of anticoagulant:
  • Low molecular weight heparin (LMWH) is preferred for patients with decompensated cirrhosis
  • Direct oral anticoagulants (DOACs) may be considered only if the patient has compensated Child-Pugh A or early B cirrhosis 1
  • Avoid vitamin K antagonists due to difficulty monitoring INR in liver failure

Perioperative Management

• Plan for bridging anticoagulation:
  • Convert to intravenous unfractionated heparin 24 hours before surgery
  • Hold heparin 4-6 hours before surgery
  • Resume anticoagulation 24-48 hours post-transplant if no bleeding complications

Risk Assessment for Retransplantation

Thrombotic Risk Factors

• DVT increases risk of perioperative complications during liver transplantation 2, 3
• Portal vein thrombosis (if present) is associated with increased 90-day mortality and graft failure 3
• Consider placement of inferior vena cava filter only if:
  • Anticoagulation is absolutely contraindicated
  • Recent PE has occurred
  • Extensive proximal DVT is present with high risk of embolization

Bleeding Risk Factors

• Liver transplant recipients have higher rates of major bleeding on anticoagulation (HR: 2.55) 4
• Carefully assess coagulation parameters (platelets, fibrinogen, INR)
• Consider thromboelastography (TEG) or rotational thromboelastometry (ROTEM) to better assess true coagulation status

Transplant Timing Considerations

• The presence of DVT alone is not an absolute contraindication to liver transplantation 1
• If cardiac function is adequate after thorough evaluation, proceed with transplant listing
• Consider delaying transplantation only if:
  • Significant inducible cardiac ischemia is found requiring intervention
  • DVT is extensive and acute (less than 2 weeks old) with high risk of embolization

Post-Transplant Considerations

• Continue DVT prophylaxis post-transplant with subcutaneous heparin, which has been shown to reduce DVT/PE events in liver transplant recipients 2
• Avoid peripherally inserted central catheters (PICCs) which significantly increase DVT/PE risk 2
• Monitor closely for hepatic artery thrombosis, which is a leading cause of graft loss 5

Conclusion

The patient can be cleared for liver retransplantation if cardiac evaluation confirms adequate cardiac function without significant inducible ischemia. The DVT should be managed with appropriate anticoagulation before, during, and after transplantation with careful monitoring for bleeding complications.